Annual Deductible/Individual
|
$1650 per individual
|
$1650 per individual
|
Annual Deductible/Family
|
$3300 per family for participating providers
|
$3300 per family for non-participating providers
|
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
|
40%
|
Inpatient Hospitalization
|
20%
|
40% subject to a benefit maximum of $600/day
|
Surgical Services Outpatient Facility Charge
|
20%
|
40% subject to a benefit maximum of $350/day
|
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
|