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 |