| In Network |
Out of Network |
Copay |
50% |
See Brochure |
Office Visits |
50% |
See Brochure |
Annual Deductible |
Individual: $10,000 Family: $20,000 |
Individual: $20,000 Family: $40,000 |
Annual Out-Of-Pocket Limit |
Individual: $5,000 Family: $10,000 (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 |
Laboratory & X-Ray |
50% |
See Brochure |
Annual Physical Exam |
No Charge. See Brochre for more details. |
See Brochure |
Annual OB-GYN Exam |
No Charge. See Brochure for more details. |
See Brochure |
Well Baby Care |
No Charge. See Brochure for more details. |
See Brochure |
Outpatient Surgery |
$200 access fee, plus 50% |
See Brochure |
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 |
Ambulance |
See Brochure for more details |
See Brochure |
Home Health Care |
See Brochure for more details
|
See Brochure |
Mental Health - Outpatient |
See Brochure for more details
|
See Brochure |
Chiropractic Care |
50% (Covered under the Outpatient Physical Medicine provision with a combined Maximum Calendar Year Benefit of $3000 per Covered Person) |
See Brochure |
Acupuncture |
See Brochure for more details |
See Brochure |
Mental Health - Inpatient |
See Brochure for more details |
See Brochure |
Chemical Dependency |
See Brochure for more details |
See Brochure |
Maternity Care |
Complications of pregnancy only, subject to coinsurance after deductible |
See Brochure |