Annual Deductible/Individual
|
$500
|
$1,000
|
Outpatient Specialist Visit
|
$30
|
50% after deductible
|
Annual Out-of-Pocket Limit/Individual
|
$2,500
|
$5,000
|
Annual Out-of-Pocket Limit/Family
|
$5,000
|
$10,000
|
Inpatient Hospitalization
|
10% after deductible
|
50% after deductible
|
Surgical Services Outpatient Facility Charge
|
10% after deductible
|
50% after deductible
|
Prescription Drug Deductible
|
$0
|
$0
|
Prescription Drugs - Generic
|
$10
|
30%
|
Prescription Drugs - Brand (Formulary/Preferred)
|
$30
|
30%
|
Prescription Drugs - Brand (Non-Formulary/Non-preferred)
|
$50
|
30%
|
Prescription Drugs - Specialty
|
30% up to $100
|
not covered
|
Chiropractic Services
|
covered up to 60 visits per year combined with other therapies
|
covered up to 60 visits per year combined with other therapies
|
Acupuncture
|
$30 up to 20 visits per year
|
$30 up to 20 visits per year
|