|
In Network |
Out of Network |
Copay |
30% |
N/A |
Office Visits |
30% |
N/A |
Annual Deductible |
Individual: $5,000 Family: $10,000 |
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 for more details |
Laboratory & X-Ray |
30% |
See brochure for more details |
Annual Physical Exam |
No Charge. See brochure for more details. |
See brochure for more details |
Annual OB-GYN Exam |
No Charge. See brochure for more details. |
See brochure for more details |
Well Baby Care |
No Charge. See brochure for more details. |
See brochure for more details |
Outpatient Surgery |
$200 access fee, plus 30% |
See brochure for more details |
Emergency Room |
$75 access fee (waived if admitted) plus 30% |
$75 access fee (waived if admitted) plus 30% |
Ambulance |
See brochure for more details |
See brochure for more details |
Home Health Care |
See brochure for more details |
See brochure for more details |
Mental Health - Outpatient |
See brochure for more details |
See brochure for more details |
Chiropractic Care |
30% (Covered under the Outpatient Physical
Medicine provision with a combined Maximum
Calendar Year Benefit
of $3000 per
Covered Person)
|
See brochure for more details |
Acupuncture |
See brochure for more details |
See brochure for more details |
Inpatient Hospital |
30% (facility fee: $750 per day for first 3 days) |
See brochure for more details |
Maternity Care |
Complications of pregnancy only, subject to coinsurance after deductible |
See brochure for more details |
Mental Health - Inpatient |
See brochure for more details |
See brochure for more details |
Chemical Dependency - Inpatient |
See brochure for more details |
See brochure for more details |
