| In Network |
Out of Network |
Copay |
No Charge after Deductible |
50% or Not Covered |
Office Visits |
No Charge after Deductible |
50% |
Annual Deductible |
Individual: $3,400 Family: $6,800 |
Individual: $6,800 Family: $13,600 |
Annual Out-Of-Pocket Limit |
Individual: $3,400 Family: $6,800 |
Individual: $8,500 Family: $17,500 |
Lifetime Maximum |
Unlimited |
Unlimited |
Prescription Drugs |
No Charge after Medical/Rx Deductible (Integrated Medical/pharmacy Deductible)
|
50% (Integrated Medical/pharmacy Deductible)
|
Laboratory & X-Ray |
No Charge after Deductible |
50% |
Annual Physical Exam |
No Charge |
50% |
Annual OB-GYN Exam |
No Charge |
50% |
Well Baby Care |
No Charge |
50% |
Outpatient Surgery |
No Charge after Deductible |
50% |
Emergency Room |
No Charge after Deductible |
50% |
Inpatient Hospital |
No Charge after Deductible |
50% |
Ambulance |
No Charge after Deductible |
50% |
Home Health Care |
No Charge after Deductible (60 days max/year combined in and out of network)
|
50% (60 days max/year combined in and out of network)
|
Mental Health - Outpatient |
No Charge after Deductible (24 days max/year combined in and out of network)
|
50% (24 days max/year combined in and out of network)
|
Chiropractic Care |
Chiro (Phy/Occ Therapy): (24 visit max/person/year combined in and out of network)
|
Chiro (Phy/Occ Therapy): 50% (24 visit max/person/year combined in and out of network)
|
Acupuncture |
Not Coveredt |
Not Covered |
Mental Health - Inpatient |
No Charge after Deductible (24 days max/year combined in and out of network) |
50% (24 days max/year combined in and out of network)
|
Chemical Dependency |
No Charge after Deductible (30 days max/year combined in and out of network)
|
50% (30 days max/year combined in and out of network)
|
Maternity Care |
Not Covered |
Not Covered |
