|
Annual Deductible/Individual
|
$4000
|
Not Covered
|
|
Annual Deductible/Family
|
$8000
|
Not Covered
|
|
Coinsurance
|
70%
|
Not covered
|
|
Office Visit/Exam
|
70% after the deductible
|
Not covered
|
|
Outpatient Specialist Visit
|
70% after the deductible
|
Not Covered
|
|
Annual Out-of-Pocket Limit/Individual
|
$6350
|
Not Covered
|
|
Annual Out-of-Pocket Limit/Family
|
$12700
|
Not Covered
|
|
Deductible Included in Out-of-Pocket Limits
|
Yes
|
Not Covered
|
|
Lifetime Plan Maximum
|
Unlimited
|
Not Covered
|
|
Preventive Care
|
100%
|
Not covered
|
|
Preventive Screenings
|
100%
|
Not covered
|
|
Well-Child Care
|
100%
|
Not covered
|
|
Immunizations
|
100%
|
Not covered
|
|
Well Woman Exams
|
100%
|
Not covered
|
|
Mammograms
|
100%
|
Not covered
|
|
Adult Periodic Exams with Preventive Tests
|
100%
|
Not covered
|
|
Inpatient Hospitalization
|
70% after the deductible
|
Not covered
|
|
Semi-Private Room & Board; Including Services and Supplies
|
70% after the deductible
|
Not covered
|
|
Surgical Services Outpatient Facility Charge
|
70% after the deductible
|
Not covered
|
|
Emergency Room
|
70% after the deductible
|
70% after the deductible
|
|
Urgent Care Facility
|
70% after the deductible
|
Not Covered
|
|
Prescription Drug Deductible
|
Combined with medical
|
Not Covered
|
|
Prescription Drugs - Generic
|
$10 after the deductible
|
Not covered
|
|
Prescription Drugs - Brand (Formulary/Preferred)
|
70% coinsurance/prescription, up to a $200 copay maximum, prescription after the deductible
|
Not covered
|
|
Prescription Drugs - Brand (Non-Formulary/Non-preferred)
|
50% coinsurance/prescription, up to a $400 copay maximum prescription 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, up to a $400 copay maximum/prescription, after the deductible
|
Not covered
|
|
Prescription Drugs Mail Order - Brand (Non-Formulary/Non-preferred)
|
50% coinsurance/prescription, up to a $800 copay maximum/prescription, 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
|
70% after the deductible
|
Not covered
|
|
Chiropractic Services
|
70% after the deductible Covered up to 30 visits
|
Not Covered
|
|
Acupuncture
|
Not covered
|
Not covered
|
|
Outpatient Rehabilitative Physical Therapy
|
70% after the deductible Covered up to 60 visits
|
Not covered
|
