| In Network |
Out of Network |
Copay |
No Charge after Deductible |
50% |
Office Visits |
No Charge after Deductible |
50% |
Annual Deductible |
Individual: $4,500 Family: $9,000 (2+ members, plan carries an embedded individual deductible, see benefit summary for details) |
Individual: $4,500 Family: $9,000 (2+ members, plan carries an embedded individual deductible, see benefit summary for details) |
Annual Out-Of-Pocket Limit |
Individual: $4,500 Family: $9,000 (Deductible included) |
Individual: $14,500 Family: $29,000 (Deductible 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 |
Not Covered |
Annual OB-GYN Exam |
No Charge |
Not Covered |
Well Baby Care |
No Charge |
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 (max 20 visits per year) |
Not Covered |
Chiropractic Care |
No Charge after Deductible
(12 visits max / year, limit $20 max / visit) |
Not Covered |
Acupuncture |
No Charge after Deductible
(12 visits max / year combined in and out of network |
Not Covered |
Mental Health - Inpatient |
|
Not Covered |
Chemical Dependency |
No Charge after Deductible (Detox only) |
50% (Detox Only) |
Maternity Care |
Not Covered |
Not Covered |
