In Network |
Out of Network |
Copay |
$20 (4 visit maximum per year) |
50% (plus all excess charges, 4 visit maximum per year) |
Office Visits |
$20 (4 visit maximum per year) |
50% (plus all excess charges, 4 visit maximum per year) |
Annual Deductible |
Individual: $5,000 |
Individual: $5,000 |
Annual Out-Of-Pocket Limit |
Individual: $5,000 |
Individual: $10,000 |
Lifetime Maximum |
Unlimited |
Unlimited |
Prescription Drugs |
$15 Generic
|
50% Drug Limited Fee Schedule |
Laboratory & X-Ray |
No Charge after Deductible
|
50% |
Annual Physical Exam |
No Charge |
50% |
Annual OB-GYN Exam |
No Charge |
50% |
Well Baby Care |
No Charge |
50% |
Outpatient Surgery |
No Charge after Deductible |
50% |
Emergency Room |
No Charge after Deductible |
No Charge after Deductible |
Inpatient Hospital |
No Charge after Deductible |
All Charges Except $650/day |
Ambulance |
No Charge after Deductible |
50% |
Home Health Care |
No Charge after Deductible (90 4-hour visits per year) |
All charges except $75 per visit (90 4-hour visits per year) |
Mental Health - Outpatient |
All charges of negotiated fee except $25 per visit (1 visit per day/20 visits per year)
|
All charges of negotiated fee except $25 per visit (1 visit per day/20 visits per year)
|
Chiropractic Care |
30% (24 visits per year)
|
All charges except $25 per visit (24 visits per year)
|
Acupuncture |
Not Covered
|
Not Covered
|
Mental Health - Inpatient |
All charges of negotiated fee except $25 per visit (1 visit per day/20 visits per year)
|
All charges of negotiated fee except $25 per visit (1 visit per day/20 visits per year)
|
Chemical Dependency |
All of the negotiated fees except $175 per day (30 days per year) |
All of the negotiated fees except $175 per day (30 days per year) |
Maternity Care |
Not Covered
|
Not Covered
|