In Network |
Out of Network |
Copay |
No Charge after Deductible |
50% |
Office Visits |
No Charge after Deductible |
50% |
Annual Deductible |
Individual: $4,000 Family: $8,000 |
Individual: $4,000 Family: $8,000 |
Annual Out-Of-Pocket Limit |
Individual: $4,000 Family: $8,000 |
Individual: $5,000 Family: $10,000 |
Lifetime Maximum |
Unlimited |
Unlimited |
Prescription Drugs |
No Charge after Deductible
|
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 |
No Charge after Deductible |
No Charge after Deductible |
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 |
Not Covered |
Not Covered |
Acupuncture |
See Benefit Contract |
See Benefits Contract |
Mental Health - Inpatient |
|
Not Covered |
Chemical Dependency |
No Charge after Deductible |
50% |
Maternity Care |
Not Covered |
Not Covered |