| In Network |
Out of Network |
Copay |
No Charge after Deductible |
No Charge after Deductible |
Office Visits |
No Charge after Deductible |
No Charge after Deductible |
| Annual Deductible |
Individual:$5,000 |
Individual:$10,000 |
| Annual Out-Of-Pocket Limit |
Individual:$5,000 |
Individual:$10,000 |
| Lifetime Maximum |
Unlimited |
Unlimited |
| Prescription Drugs |
No Charge after Medical/Rx Deductible
|
No Charge after Medical/Rx Deductible |
| Laboratory & X-Ray |
No Charge after Deductible |
No Charge after Deductible |
| Annual Physical Exam |
No Charge |
No Charge after Deductible |
| Annual OB-GYN Exam |
No Charge |
No Charge after Deductible |
Well Baby Care |
No Charge |
No Charge after Deductible |
| Outpatient Surgery |
No Charge after Deductible |
No Charge after Deductible |
| Emergency Room |
No Charge after Deductible |
No Charge after Deductible |
| Inpatient Hospital |
No Charge after Deductible |
No Charge after Deductible |
| Ambulance |
No Charge after Deductible |
No Charge after Deductible |
| Home Health Care |
No Charge after Deductible |
No Charge after Deductible |
| Mental Health - Outpatient |
Not Covered |
Not Covered |
| Chiropractic Care |
See Brochure |
See Brochure |
Acupuncture |
Not Covered |
Not Covered |
| Mental Health - Inpatient |
Not Covered
|
Not Covered |
| Chemical Dependency |
Not Covered |
Not Covered |
| Maternity Care |
Not Covered |
Not Covered |
