Deductible Amount
(Maximum of 2 deductibles per family, per calendar year.) |
$500 OR $1,000** |
$2,500, $5,000 OR $10,000** |
| Maximum Lifetime Benefit |
$5,000,000 per covered member. |
$5,000,000 per covered member. |
| Coinsurance |
You pay 20% coinsurance after the deductible has been met. |
You pay 0% coinsurance after the deductible has been met. |
Your Out-of-Pocket Coinsurance Maximum
(Maximum of 2 calendar-year coinsurance maximums per family, per calendar year.) |
$2,000 |
Not applicable. |
Primary Care Physician Office Visit
(In-network general practitioners, pediatricians, family practitioners and internal medicine doctors.) |
You pay a $30 copay.
|
You pay a $30 copay. |
| Specialist Office Visit |
You pay a $60 copay.*** |
You pay a $60 copay.*** |
Inpatient Services
(Facility and physician.) |
You pay 20% coinsurance after the deductible has been met. |
You pay 0% coinsurance after the deductible has been met. |
Outpatient Services
(Facility and physician.) |
You pay 20% coinsurance after the deductible has been met. |
You pay 0% coinsurance after the deductible has been met. |
Emergency Room
(Facility only.) |
You pay a $200 copayment (waived if admitted). Deductible does not apply. |
You pay a $200 copayment (waived if admitted). Deductible does not apply. |
Children’s Preventive Services
(Immunizations and well-patient care [office visits only].) |
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 20% coinsurance. Deductible does not apply. $500 annual maximum. |
You pay 0% coinsurance. Deductible does not apply. $500 annual maximum. |
| Psychiatric Conditions/Substance Abuse Benefits |
You pay 50% coinsurance after the deductible has been met. $4,000 annual maximum. |
You pay 50% coinsurance after the deductible has been met. $4,000 annual maximum. |
| Prescription Drugs |
You pay a $10 copay for generics; $35 copay for preferred brands; $70 copay for non-preferred brands. |
You pay a $10 copay for generics; $35 copay for preferred brands; $70 copay for non-preferred brands. |
Hospice
(Subject to prior approval.) |
You pay 20% coinsurance after the deductible has been met. |
You pay 0% coinsurance after the deductible has been met. |
Hearing Aid Coverage
|
Not Covered |
Not Covered |
| Optional Riders |
- Maternity Benefits
(Covered only if Maternity
Benefit Rider is added to
the policy.)
|
| |
- Mental Health Parity Benefits
(Covered only if Mental Health
Parity Rider is added to the
policy.)
- Office Visit
- Inpatient and Outpatient
Services (Some services
require prior approval.)
|
|
| |
| You pay 20% coinsurance after the deductible has been met. Coinsurance does not apply toward the annual out-of-pocket maximum. |
You pay a $60 copay.***
You pay 20% coinsurance
after the deductible has
been met. |
|
| |
| You pay 0% coinsurance after the deductible has been met. |
You pay a $60 copay.***
You pay 0% coinsurance
after the deductible has
been met. |
|