In Network |
Out of Network |
Copay |
$40 first 2 visits then 100% of negotiated fee after OOP max is met |
No Charge after Deductible then 50% after OOP max is met |
Office Visits |
No Charge after Deductible |
30% |
Annual Deductible |
Individual: $1,000 Family: $2,000 |
Individual: $1,000 Family: $2,000 |
Annual Out-Of-Pocket Limit |
Individual: $4,500 Family: $9,000 |
Individual: $4,500 Family: $9,000 |
Lifetime Maximum |
Unlimited |
Unlimited |
Prescription Drugs |
Tier 1: $15
Tier 2: $40
Tier 3: $60
($7,500 Deductible / member / Tier 2 & 3) |
Not Covered |
Laboratory & X-Ray |
100% of negotiated fee then No Charge after OOP max is met |
100% of negotiated fee then 50% after OOP max is met |
Annual Physical Exam |
No Charge |
No Charge after Deductible then 50% after OOP max is met |
Annual OB-GYN Exam |
No Charge |
No Charge after Deductible then 50% after OOP max is met |
Well Baby Care |
No Charge |
No Charge after Deductible then 50% after OOP max is met |
Outpatient Surgery |
40% |
30% |
Emergency Room |
100% (Waived if admitted) plus 40% |
100% (Waived if admitted) plus 40% |
Inpatient Hospital |
No Charge after Deductible |
All Charges Except $650 / day after Deductible |
Ambulance |
See Brochure |
See Brochure |
Home Health Care |
See Brochure |
See Brochure |
Mental Health - Outpatient |
See Brochure |
See Brochure |
Chiropractic Care |
See Brochure |
See Brochure |
Acupuncture |
See Brochure |
See Brochure |
Mental Health - Inpatient |
See Brochure |
See Brochure |
Chemical Dependency |
See Brochure |
See Brochure |
Maternity Care |
Not Covered |
Not Covered |