Annual
Deductible |
In |
Individual:
$4,500 Family: $9,000 |
Individual:
$3,500 Family: $7,000 |
Individual:
$2,500 Family: $5,000 |
|
Out |
Individual:
$13,500 Family: $21,000 |
Individual:
$10,500 Family: $21,000 |
Individual:
$7,500 Family: $15,000 |
Out
of Pocket Maximum |
In |
Individual:
$9,500 Family: $19,000 |
Individual:
$8,500 Family: $17,000 |
Individual:
$7,500 Family: $15,000 |
|
Out |
Individual:
$23,500 Family: $47,000 |
Individual:
$20,500 Family: $31,000 |
Individual:
$17,500 Family: $35,000 |
Lifetime
Maximum |
In |
None |
None |
None |
|
Out |
None |
None |
None |
Doctors'
Office Visits |
In |
$45
(Deductible waived for first
two visits per year) |
$35
(Deductible waived for first
two visits per year) |
$25
(Deductible waived for first
two visits per year) |
|
Out |
50% |
50% |
50% |
X-ray
and laboratory |
In |
45% |
35% |
25% |
|
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 45% |
$100
per visit (waived if admitted)
then 35% |
$100
per visit (waived if admitted)
then 25% |
|
Out |
$100
per visit (waived if admitted)
then 45% |
$100
per visit (waived if admitted)
then 35% |
$100
per visit (waived if admitted)
then 25% |
Ambulance
Services |
In |
45% |
35% |
25% |
|
Out |
45% |
35% |
25% |
Outpatient
Surgery |
In |
45% |
35% |
25% |
|
Out |
50% |
50% |
50% |
Inpatient
Hospital |
In |
45% |
35% |
25% |
|
Out |
50% |
50% |
50% |
Chemical
Dependency Services |
In |
45% |
35% |
25% |
|
Out |
50% |
50% |
50% |
Maternity |
In |
45% |
35% |
25% |
|
Out |
50% |
50% |
50% |
Home
Health Care |
In |
45%
(90 visits per year) |
35%
(90 visits per year) |
25%
(90 visits per year) |
|
Out |
Not
Covered |
Not
Covered |
Not
Covered |
Mental
Health - Outpatient |
In |
45%
(20 visits per year) |
35%
(20 visits per year) |
25%
(20 visits per year) |
|
Out |
Not
Covered |
Not
Covered |
Not
Covered |
Mental
Health - Inpatient |
In |
45% |
35% |
25% |
|
Out |
50% |
50% |
50% |
Chiropractic
care |
In |
50%
(12 visits per year, pays
a maximum of $25 per visit,
see brochure) |
50%
(12 visits per year, pays
a maximum of $25 per visit,
see brochure) |
50%
(12 visits per year, pays
a maximum of $25 per visit,
see brochure) |
|
Out |
Not
Covered |
Not
Covered |
Not
Covered |
Acupuncture |
In |
50%
(12 visits per year, pays
a maximum of $25 per visit,
see brochure) |
50%
(12 visits per year, pays
a maximum of $25 per visit,
see brochure) |
50%
(12 visits per year, pays
a maximum of $25 per visit,
see brochure) |
|
Out |
50%
(12 visits per year, pays
a maximum of $25 per visit,
see brochure) |
50%
(12 visits per year, pays
a maximum of $25 per visit,
see brochure) |
50%
(12 visits per year, pays
a maximum of $25 per visit,
see brochure) |
