| 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 |
$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 |
| Annual Deductible |
Individual: $5,000 Family: $10,000 |
Individual: $5,000 Family: $10,000 |
| Annual Out-Of-Pocket Limit |
Individual: $8,500 Family: $17,000 |
Individual: $8,500 Family: $17,000 |
| 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% |
All charges except $380/day after Deductible
|
| 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 |
