| In Network |
Out of Network |
Copay |
30% |
50% or Not Covered |
Office Visits |
Primary: $30 Specialist: $40 |
50% |
Annual Deductible |
Individual: $5,000 Family: $10,000 |
Individual: $10,000 Family: $20,000 |
Annual Out-Of-Pocket Limit |
Individual: $5,000 Family: $10,000 (Deductible not included) |
Individual: $10,000 Family: $20,000
(Deductible not included) |
Lifetime Maximum |
Unlimited |
Unlimited |
Prescription Drugs |
Generic: $10
Brand Formulary: $35
Brand Non-Formulary: $60
(30 day, $500 Brand Deductible) |
50% ($500 Brand Deductible)
|
Laboratory & X-Ray |
30% |
50% |
Annual Physical Exam |
No Charge |
50% |
Annual OB-GYN Exam |
No Charge |
50% |
Well Baby Care |
No Charge |
50% |
Outpatient Surgery |
30% |
50% |
Emergency Room |
$100 additional deductible, then 30% (Additional deductible waived if admitted)
|
$100 additional deductible, then 50% (Additional deductible waived if admitted) |
Inpatient Hospital |
30% |
50% |
Ambulance |
30% |
50% |
Home Health Care |
30% (30 days max/year combined in and out of network)
|
50% (30 days max/year combined in and out of network)
|
Mental Health - Outpatient |
30% (20 days max/year combined in and out of network)
|
50% (20 days max/year combined in and out of network)
|
Chiropractic Care |
Chiro (Phy/Occ Therapy): 30% (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 |
30% (20 days max/year combined in and out of network) |
50% (20 days max/year combined in and out of network)
|
Chemical Dependency |
30% (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 |
