|
Annual Deductible/Individual
|
$1600.00
|
$3000.00
|
|
Annual Deductible/Family
|
$3200.00
|
$6000.00
|
|
Coinsurance
|
90%
|
70%
|
|
Office Visit/Exam
|
90% after deductible
|
70% after deductible
|
|
Outpatient Specialist Visit
|
90% after deductible
|
70% after deductible
|
|
Annual Out-of-Pocket Limit/Individual
|
$6000.00
|
$6000.00
|
|
Annual Out-of-Pocket Limit/Family
|
$6000.00
|
$12000.00
|
|
Preventive Care
|
100%
|
70% after deductible
|
|
Inpatient Hospitalization
|
90% after deductible
|
70% after deductible
|
|
Surgical Services Outpatient Facility Charge
|
90% after deductible
|
70% after deductible
|
|
Emergency Room
|
90% after deductible
|
70% after deductible
|
|
Urgent Care Facility
|
90% after deductible
|
70% after deductible
|
|
Prescription Drug Deductible
|
Combined with Medical deductible
|
Combined with Medical deductible
|
|
Prescription Drugs - Generic
|
$10.00 after deductible retail 30 days; $25 after deductible for retail 90 days
|
50% after deductible
|
|
Prescription Drugs - Brand (Formulary/Preferred)
|
$30.00 after deductible retail 30 days; $75 after deductible retail 90 days
|
50% after deductible
|
|
Prescription Drugs - Brand (Non-Formulary/Non-preferred)
|
$50.00 after deductible retail 30 days; $125 after deductible retail 90 days
|
50% after deductible
|
|
Prescription Drugs - Specialty
|
N/A
|
N/A
|
|
Chiropractic Services
|
90% after deductible; up to 25 visits per year
|
70% after deductible; up to 25 visits per year
|
|
Acupuncture
|
90% after deductible; up to 20 visits per year
|
Not covered
|
|
Employer Contributions Individual
|
$1,000
|
-
|
|
Employer Contributions Family
|
$2,000 per family
|
- per family
|
