| In Network |
Out of Network |
Copay |
See Brochure |
See Brochure |
Office Visits |
See Brochure |
See Brochure |
| Annual Deductible |
$7,500 per member / 2 member maximum |
$7,500 per member / 2 member maximum |
| Annual Out-Of-Pocket Limit |
$7,500 per member / 2 member maximum |
$7,500 per member / 2 member maximum |
| Lifetime Maximum |
Unlimited |
Unlimited |
| Prescription Drugs |
$15 or 40% whichever is greater ($750 Brand Deductible, See Brochure)
|
$750 Brand Deductible then 50% of negotiated fees plus all excess charges ( See Brochure) |
| Laboratory & X-Ray |
No Carge after Deductible |
No Charge after Deductible |
| Annual Physical Exam |
No Charge |
See Brochure |
| Annual OB-GYN Exam |
No Charge |
See Brochure |
Well Baby Care |
No Charge |
See Brochure |
| Outpatient Surgery |
No Carge after Deductible |
See Brochure |
| Emergency Room |
No Carge after Deductible plus $100 (waived if admitted) |
See Brochure |
| Inpatient Hospital |
No Carge after Deductible |
See Brochure |
| Ambulance |
No Carge after Deductible |
No Carge after Deductible |
| Home Health Care |
See Brochure |
See Brochure |
| Mental Health - Outpatient |
See Brochure |
See Brochure |
| Chiropractic Care |
See Brochure |
See Brochure |
Acupuncture |
Not Covered |
Not Applicable |
| Mental Health - Inpatient |
See Brochure |
See Brochure |
| Chemical Dependency |
See Brochure |
See Brochure |
| Maternity Care |
No Carge after Deductible |
No Carge after Deductible |
