| In Network |
Out of Network |
Copay |
50% |
See Brochure and state variations for more details |
Office Visits |
50% |
See Brochure and state variations for more details |
| Annual Deductible |
Individual: $10,000 Family: $20,000 |
Individual: $20,000 Family: $40,000 |
| Annual Out-Of-Pocket Limit |
Individual: $7,500 Family: $15,000 (Deductible not included) |
Individual: $10,000 Family: $20,000 (Deductible not Included) |
| Lifetime Maximum |
Not Applicable |
Not Applicable |
| Prescription Drugs |
Subject to plan deductible and coinsurance
|
See Brochure and state variations for more details |
| Laboratory & X-Ray |
50% |
See Brochure and state variations for more details |
| Annual Physical Exam |
No Charge. See brochure and state variations for more details.
|
See Brochure and state variations for more details |
| Annual OB-GYN Exam |
No Charge. See brochure and state variations for more details. |
See Brochure and state variations for more details |
Well Baby Care |
No Charge. See brochure and state variations for more details. |
See Brochure and state variations for more details |
| Outpatient Surgery |
$200 access fee, plus 50% |
See Brochure and state variations for more details |
| Emergency Room |
$75 access fee (waived if admitted) plus 50% |
$75 access fee (waived if admitted) plus 50% |
| Inpatient Hospital |
50% (facility fee: $750 per day for first 3 days) |
See Brochure and state variations for more details |
| Ambulance |
See Brochure and state variations for more details |
See Brochure and state variations for more details |
| Home Health Care |
See Brochure and state variations for more details |
See Brochure and state variations for more details |
| Mental Health - Outpatient |
See Brochure and state variations for more details |
See Brochure and state variations for more details |
| Chiropractic Care |
50% (Covered under the Outpatient Physical Medicine provision with a combined Maximum Calendar Year Benefit of $3000 per Covered Person) |
See Brochure and state variations for more details |
Acupuncture |
See Brochure and state variations for more details |
See Brochure and state variations for more details |
| Mental Health - Inpatient |
See Brochure and state variations for more details |
See Brochure and state variations for more details |
| Chemical Dependency |
See Brochure and state variations for more details |
See Brochure and state variations for more details |
| Maternity Care |
Complications of pregnancy only, subject to coinsurance after deductible
|
See Brochure and state variations for more details |
