In Network |
Out of Network |
Copay |
No Charge after Deductible |
50% or Not Covered |
Office Visits |
No Charge after Deductible |
50% |
Annual Deductible |
Individual: $3,500 Family: $7,000 |
Individual: $5,000 Family: $10,000 |
Annual Out-Of-Pocket Limit |
Individual: $5,000 Family: $10,000 |
Individual: $15,000 Family: $30,000 |
Lifetime Maximum |
Unlimited |
Unlimited |
Prescription Drugs |
AFTER DEDUCTIBLE
Generic: $10
Brand Formulary: $35
Brand Non-Formulary $50 or 50%, whichever is greater (Maximum of $150 per perscription) |
Not Covered |
Laboratory & X-Ray |
No Charge after Deductible |
50% |
Annual Physical Exam |
No Charge |
Not Covered |
Annual OB-GYN Exam |
No Charge |
Not Covered |
Well Baby Care |
No Charge |
Not Covered |
Outpatient Surgery |
No Charge after Deductible |
50% |
Emergency Room |
$100 / visit (waived if admitted) |
$100 / visit (waived if admitted) |
Inpatient Hospital |
No Charge after Deductible |
50% |
Ambulance |
No Charge after Deductible |
No Charge after Deductible |
Home Health Care |
No Charge after Deductible (90 visits per year) |
Not Covered |
Mental Health - Outpatient |
No Charge after Deductible (20 visits per year) |
Not Covered |
Chiropractic Care |
30% (maximum benefit $25 per visit, 12 visit per year) |
Not Covered |
Acupuncture |
See Benefit Contract |
See Benefit Contract |
Mental Health - Inpatient |
|
Not Covered |
Chemical Dependency |
No Charge after Deductible |
50% |
Maternity Care |
Not Covered |
Not Covered |