|
Annual Deductible/Individual
|
$1600 per individual
|
$1600 per individual
|
|
Annual Deductible/Family
|
$3200 per family for participating providers
|
$3200 per family for non-participating providers
|
|
Coinsurance
|
20%
|
40%
|
|
Office Visit/Exam
|
20%
|
40%
|
|
Outpatient Specialist Visit
|
20%
|
40% subject to benefit max $350/per day
|
|
Annual Out-of-Pocket Limit/Individual
|
$4500 per individual
|
$4500 per individual
|
|
Annual Out-of-Pocket Limit/Family
|
$6850 per family for participating providers
|
$6850 per family for non-participating providers
|
|
Preventive Care
|
0% ; deductible does not apply No copay
|
40%
|
|
Inpatient Hospitalization
|
20%
|
40% subject to a benefit maximum of $600/day subject to benefit max $600/per day
|
|
Surgical Services Outpatient Facility Charge
|
20%
|
40% subject to a benefit maximum of $350/day subject to benefit max $350/per day
|
|
Emergency Room
|
20%
|
20%
|
|
Urgent Care Facility
|
20%
|
40%
|
|
Prescription Drug Deductible
|
Combined with medical deductible
|
Combined with medical deductible
|
|
Prescription Drugs - Generic
|
$10 Retail: /prescription
|
Not Covered
|
|
Prescription Drugs - Brand (Formulary/Preferred)
|
$30 Retail: /prescription
|
Not Covered
|
|
Prescription Drugs - Brand (Non-Formulary/Non-preferred)
|
$50 Retail: /prescription
|
Not Covered
|
|
Prescription Drugs - Specialty
|
$100 Retail and Network Specialty Pharmacies: /prescription
|
Not Covered
|
|
Chiropractic Services
|
20% up to 20 visits per year
|
40% up to 20 visits per year
|
|
Acupuncture
|
Not covered
|
Not covered
|
