In Network |
Out of Network |
Copay |
No Charge after Deductible |
50% |
Office Visits |
No Charge after Deductible |
50% |
Annual Deductible |
Individual: $5,200 Family: $10,400 |
Individual: $5,200 Family: $10,400 |
Annual Out-Of-Pocket Limit |
Individual: $4,500 Family: $9,000 (Deductible included) |
Individual: $5,000 Family: $10,000
( Deductible not Included) |
Lifetime Maximum |
Unlimited |
Unlimited |
Prescription Drugs |
No Charge after Medical / Rx Deductible
|
Not Covered |
Laboratory & X-Ray |
No Charge after Deductible
|
50% |
Annual Physical Exam |
No Charge (Deductible Waived) |
Not Covered |
Annual OB-GYN Exam |
No Charge (Deductible Waived) |
Not Covered |
Well Baby Care |
No Charge (Deductible Waived) |
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 |
50% |
Mental Health - Outpatient |
No Charge after Deductible |
Not Covered |
Chiropractic Care |
No Charge after Deductible
(12 visits per calendar year maximum) |
50% (12 visits per calendar year maximum) |
Acupuncture |
Not Covered |
Not Covered |
Chemical Dependency |
No Charge after Deductible
(Detox only) |
50% (Detox Only) |
Maternity Care |
Not Covered |
Not Covered |