| In Network |
Out of Network |
Copay |
20% |
20% |
Office Visits |
$30, first 2 visits then 20% |
Eligible charges reduced additional 20% per occurrence. |
Annual Deductible |
Individual: $2,500 Family: $7,500 |
Individual: $4,000 Family: $12,000 |
Annual Out-Of-Pocket Limit |
Individual: $4,500 Family: $13,500 |
None
|
Lifetime Maximum |
Not Applicable |
Not Applicable |
Prescription Drugs |
Generic: $15
Preferred Brand: 35%
Non-Preferred Brand: 50%
($1,000 Brand Deductible) |
Not Covered |
Laboratory & X-Ray |
20% |
Eligible charges reduced additional 20% per occurrence. |
Annual Physical Exam |
No Charge |
Eligible charges reduced additional 20% per occurrence.
|
Annual OB-GYN Exam |
No Charge |
Eligible charges reduced additional 20% per occurrence.
|
Well Baby Care |
No Charge |
Eligible charges reduced additional 20% per occurrence.
|
Outpatient Surgery |
$350 per admission plus 20% |
Eligible charges reduced additional 20% per occurrence. |
Emergency Room |
20% plus $250
(waived if admitted) |
20% plus $250
(waived if admitted) |
Inpatient Hospital |
$500 per admission plus 20% |
Eligible charges reduced additional 20% per occurrence. |
Ambulance |
20% ($3,000 maximum benefit per year)
|
20% ($3,000 maximum benefit per year) |
Home Health Care |
20% (20 visits per year) |
Eligible charges reduced additional 20% per occurrence. |
Mental Health - Outpatient |
Not Covered |
Not Covered |
Chiropractic Care |
Not Covered |
Not Covered |
Acupuncture |
Not Covered |
Not Covered |
Mental Health - Inpatient |
Not Covered |
Not Covered |
Chemical Dependency |
See Benefit Contract |
See Benefit Contract |
Maternity Care |
Not Covered |
Not Covered |
