| In Network |
Out of Network |
Copay |
20% |
N/A |
Office Visits |
$15, first 2 visits then 20% Coinsurance after Deductible |
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: $10
Brand Formulary: $40
Brand Non-Formulary: 30%
($500 Brand Deductible) |
Not Covered |
Laboratory & X-Ray |
20%
Coinsurance after deductible |
20% Coinsurance after deductible |
Annual Physical Exam |
No Charge |
Optional Rider Available |
Annual OB-GYN Exam |
No Charge |
Optional Rider Available |
Well Baby Care |
No Charge |
Optional Rider Available |
Outpatient Surgery |
20% |
Eligible charges reduced additional 20% per occurrence. |
Emergency Room |
20% plus $250
(waived if admitted) |
20% plus $250 (waived if admitted)
|
Inpatient Hospital |
20% |
Eligible charges reduced additional 20% per occurrence. |
Ambulance |
20% ($5,000 maximum benefit per year)
|
20% ($5,000 maximum benefit per year) |
Home Health Care |
20% (30 visits per year) |
Eligible charges reduced additional 20% per occurrence. |
Mental Health - Outpatient |
50% up to $40 per visit ($1,000 maximum benefit per year, $10,000 lifetime maximum benefit) |
Eligible charges reduced additional 20% per occurrence. |
Chiropractic Care |
20% ($500 maximum benefit per year) |
Eligible charges reduced additional 20% per occurrence. |
Acupuncture |
Not Covered |
Not Covered |
Mental Health - Inpatient |
50% up to $40 per visit ($1,000 maximum benefit per year, $10,000 lifetime maximum benefit) |
Eligible charges reduced additional 20% per occurrence. |
Chemical Dependency |
Not Covered |
Not Covered |
Maternity Care |
Not Covered |
Not Covered |
