|
Annual Deductible/Individual
|
$1000
|
$4000
|
|
Annual Deductible/Family
|
$2000
|
$8000
|
|
Coinsurance
|
85%
|
60% after the deductible
|
|
Office Visit/Exam
|
$30 copay
|
60% after the deductible
|
|
Outpatient Specialist Visit
|
$60 copay
|
60% after the deductible
|
|
Annual Out-of-Pocket Limit/Individual
|
$3000
|
$8000
|
|
Annual Out-of-Pocket Limit/Family
|
$6000
|
$16000
|
|
Deductible Included in Out-of-Pocket Limits
|
Yes
|
Yes
|
|
Lifetime Plan Maximum
|
Unlimited
|
Unlimited
|
|
Preventive Care
|
100%
|
60% after the deductible
|
|
Preventive Screenings
|
100%
|
60% after the deductible
|
|
Well-Child Care
|
100%
|
60% after the deductible
|
|
Immunizations
|
100%
|
60% after the deductible
|
|
Well Woman Exams
|
100%
|
60% after the deductible
|
|
Mammograms
|
100%
|
60% after the deductible
|
|
Adult Periodic Exams with Preventive Tests
|
100%
|
60% after the deductible
|
|
Inpatient Hospitalization
|
$500 copay/admission, plus 85% coinsurance
|
60% after the deductible
|
|
Semi-Private Room & Board; Including Services and Supplies
|
$500 copay/admission, plus 85% coinsurance
|
60% after the deductible
|
|
Surgical Services Outpatient Facility Charge
|
$250 copay/visit, plus 85% coinsurance. Deductible does not apply
|
60% after the deductible
|
|
Emergency Room
|
$200 per visit
|
$200 per visit
|
|
Urgent Care Facility
|
$60 per visit
|
60% after the deductible
|
|
Prescription Drug Deductible
|
N/A
|
Not Covered
|
|
Prescription Drugs - Generic
|
$10
|
Not covered
|
|
Prescription Drugs - Brand (Formulary/Preferred)
|
70% coinsurance/prescription, up to a $200 maximum (retail), after the deductible
|
Not covered
|
|
Prescription Drugs - Brand (Non-Formulary/Non-preferred)
|
50% coinsurance/prescription, up to a $400 maximum (retail) after the deductible after the deductible
|
Not covered
|
|
Prescription Drugs - Number of Days Supply
|
30 days
|
Not Covered
|
|
Prescription Drugs Mail Order - Generic
|
$20 after the deductible
|
Not covered
|
|
Prescription Drugs Mail Order - Brand (Formulary/Preferred)
|
70% coinsurance/prescription, after deductible up to a $400 maximum, after the deductible
|
Not covered
|
|
Prescription Drugs Mail Order - Brand (Non-Formulary/Non-preferred)
|
50% coinsurance/prescription, after deductible up to a $800 maximum, after the deductible
|
Not covered
|
|
Prescription Drugs Mail Order - Number of Days Supply for Mail Order
|
90 days
|
Not Covered
|
|
Durable Medical Equipment & Prosthetic Devices
|
85% after the deductible
|
60% after the deductible
|
|
Chiropractic Services
|
$60 copay, deductible does not apply Covered up to 30 visits
|
60% after the deductible Covered up to 30 visits
|
|
Acupuncture
|
Not covered
|
Not covered
|
|
Outpatient Rehabilitative Physical Therapy
|
$60 copay. Covered up to 60 visits
|
60% after the deductible. Covered up to 60 visits
|
