Annual
Deductible |
In |
Individual:
$6,000 Family: $12,000 |
Individual:
$4,000 Family: $8,000 |
Individual:
$2,000 Family: $4,000 |
|
Out |
Individual:
$6,000 Family: $12,000 |
Individual:
$4,000 Family: $8,000 |
Individual:
$2,000 Family: $4,000 |
Out
of Pocket Maximum |
In |
Individual:
$10,000 Family: $20,000 |
Individual:
$8,000 Family: $16,000 |
Individual:
$6,000 Family: $12,000 |
|
Out |
Individual:
$13,000 Family: $26,000 |
Individual:
$11,000 Family: $22,000 |
Individual:
$9,000 Family: $18,000 |
Lifetime
Maximum |
In |
None |
None |
None |
|
Out |
None |
None |
None |
Doctors'
Office Visits |
In |
$30 |
$30 |
$30 |
|
Out |
50% |
50% |
50% |
X-ray
and laboratory |
In |
40% |
40% |
40% |
|
Out |
50% |
50% |
50% |
Rx
Copay/Coinsurance |
In |
Generic:
$10 Brand Formulary:
$35 Brand Non-Formulary:
Greater of $60 or
50%, $150 max per
prescription ($3,000
Brand Deductible/person) |
Generic:
$10 Brand Formulary:
$35 Brand Non-Formulary:
Greater of $60 or
50%, $150 max per
prescription ($3,000
Brand Deductible/person) |
Generic:
$10 Brand Formulary:
$35 Brand Non-Formulary:
Greater of $60 or
50%, $150 max per
prescription ($3,000
Brand Deductible/person) |
|
Out |
Not
Covered |
Not
Covered |
Not
Covered |
Annual
Physical Exam |
In |
No
Charge |
No
Charge |
No
Charge |
|
Out |
Not
Covered |
Not
Covered |
Not
Covered |
Annual
Routine Gyn Exam |
In |
No
Charge |
No
Charge |
No
Charge |
|
Out |
Not
Covered |
Not
Covered |
Not
Covered |
Well
Baby Care |
In |
No
Charge |
No
Charge |
No
Charge |
|
Out |
Not
Covered |
Not
Covered |
Not
Covered |
Emergency
Room Services |
In |
$100
per visit (waived
if admitted) then
40% |
$100
per visit (waived
if admitted) then
40% |
$100
per visit (waived
if admitted) then
40% |
|
Out |
$100
per visit (waived
if admitted) then
40% |
$100
per visit (waived
if admitted) then
40% |
$100
per visit (waived
if admitted) then
40% |
Ambulance
Services |
In |
40% |
40% |
40% |
|
Out |
40% |
40% |
40% |
Outpatient
Surgery |
In |
40% |
40% |
40% |
|
Out |
50% |
50% |
50% |
Inpatient
Hospital |
In |
40% |
40% |
40% |
|
Out |
50% |
50% |
50% |
Chemical
Dependency Services |
In |
40% |
40% |
40% |
|
Out |
50% |
50% |
50% |
Maternity |
In |
40% |
40% |
40% |
|
Out |
50% |
50% |
50% |
Home
Health Care |
In |
40%
(90 visits per year) |
40%
(90 visits per year) |
40%
(90 visits per year) |
|
Out |
Not
Covered |
Not
Covered |
Not
Covered |
Mental
Health - Outpatient |
In |
40%
(20 visits per year) |
40%
(20 visits per year) |
40%
(20 visits per year) |
|
Out |
Not
Covered |
Not
Covered |
Not
Covered |
Mental
Health - Inpatient |
In |
40% |
40% |
40% |
|
Out |
50% |
50% |
50% |
Chiropractic
care |
In |
50%
(12 visits / year,
pays up tp $25 /visit,
see brochure) |
50%
(12 visits / year,
pays up tp $25 /visit,
see brochure) |
50%
(12 visits / year,
pays up tp $25 /visit,
see brochure) |
|
Out |
Not
Covered |
Not
Covered |
Not
Covered |
Acupuncture |
In |
50%
(12 visits / year,
pays up tp $25 /visit,
see brochure) |
50%
(12 visits / year,
pays up tp $25 /visit,
see brochure) |
50%
(12 visits / year,
pays up tp $25 /visit,
see brochure) |
|
Out |
50%
(12 visits / year,
pays up tp $25 /visit,
see brochure) |
50%
(12 visits / year,
pays up tp $25 /visit,
see brochure) |
50%
(12 visits / year,
pays up tp $25 /visit,
see brochure) |
