| In Network |
Out of Network |
Copay |
No Charge after Deductible |
See brochure and state variations for more details |
Office Visits |
No Charge after Deductible |
Eligible charges reduced additional 20% per occurrence. |
Annual Deductible |
Individual: $25,000 Family: $50,000
|
Individual: $26,000 Family: $52,000 |
Annual Out-Of-Pocket Limit |
Individual: $25,000 Family: $50,000
(Deductible not included) |
Individual: $40,000 Family: $80,000
(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 |
No Charge after Deductible |
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, No Charge after deductible |
See brochure and state variations for more details |
Emergency Room |
$75 access fee (waived if admitted) No Charge after Deductible
|
$75 access fee (waived if admitted) No Charge after Deductible
|
Inpatient Hospital |
No Charge after Deductible (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 |
No Charge after Deductible (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 |
