Deductible Amount (Aggregate family deductible*;
no deductible carryover.) |
$1,500 Individual
$3,000 Family |
$2,500 Individual
$5,000 Family |
$ 5,000 Individual
$10,000 Family |
| Maximum Lifetime Benefit |
Unlimited |
Unlimited |
Unlimited |
| Coinsurance |
You pay 0% coinsurance after the deductible has been met. |
You pay 0% coinsurance after the deductible has been met. |
You pay 0% coinsurance after the deductible has been met. |
| Calendar-Year Coinsurance Maximum |
Not applicable. |
Not applicable. |
Not applicable. |
Primary Care Physician Office Visit
(In-network general practitioners, pediatricians, family practitioners and internal medicine doctors.) |
You pay 0% coinsurance after the deductible has been met.
|
You pay 0% coinsurance after the deductible has been met. |
You pay 0% coinsurance after the deductible has been met. |
| Specialist Office Visit |
You pay 0% coinsurance after the deductible has been met. |
You pay 0% coinsurance after the deductible has been met. |
You pay 0% coinsurance after the deductible has been met. |
| Inpatient Services |
You pay 0% coinsurance after the deductible has been met. |
You pay 0% coinsurance after the deductible has been met. |
You pay 0% coinsurance after the deductible has been met. |
| Outpatient Services |
You pay 0% coinsurance after the deductible has been met. |
You pay 0% coinsurance after the deductible has been met. |
You pay 0% coinsurance after the deductible has been met. |
| Emergency Room |
You pay 0% coinsurance after the deductible has been met. |
You pay 0% coinsurance after the deductible has been met. |
You pay 0% coinsurance after the deductible has been met. |
Children’s Preventive Services
(Immunizations and well-patient care.) |
You pay 0% coinsurance. Deductible does not apply. |
You pay 0% coinsurance. Deductible does not apply. |
You pay 0% coinsurance. Deductible does not apply. |
Wellness Services
- Routine physical exams
- Routine gynecological exams
- Routine mammograms
- Routine PSA tests
|
You pay 0% coinsurance. Deductible does not apply. |
You pay 0% coinsurance. Deductible does not apply. |
You pay 0% coinsurance. Deductible does not apply. |
| Psychiatric Conditions/Substance Abuse Benefits |
Not covered. |
Not covered. |
Not covered. |
| Prescription Drugs |
You pay 0% after the deductible has been met. |
You pay 0% after the deductible has been met. |
You pay 0% after the deductible has been met. |
Hospice
(Subject to prior approval.) |
You pay 0% coinsurance after the deductible has been met. |
You pay 0% coinsurance after the deductible has been met. |
You pay 0% coinsurance after the deductible has been met. |
Maternity Benefits - Optional
(Covered only if maternity rider is added to policy.) |
You pay 0% coinsurance after the deductible has been met. |
You pay 0% coinsurance after the deductible has been met. |
You pay 0% coinsurance after the deductible has been met. |
| Tax Advantages |
Yes |
Yes |
Yes |