|
Annual Deductible/Individual
|
$1,650 per individual / $3,300 per family member
|
$1,650 per individual / $3,300 per family member
|
|
Annual Deductible/Family
|
$3,300
|
$3,300
|
|
Coinsurance
|
20%
|
40%
|
|
Office Visit/Exam
|
20%
|
40%
|
|
Outpatient Specialist Visit
|
20%
|
40%
|
|
Annual Out-of-Pocket Limit/Individual
|
$4,500 per individual / $4,500 per family member
|
$4,500 per individual / $4,500 per family member
|
|
Annual Out-of-Pocket Limit/Family
|
$6,850
|
$6,850
|
|
Deductible Included in Out-of-Pocket Limits
|
Yes
|
Yes
|
|
Lifetime Plan Maximum
|
Unlimited
|
Unlimited
|
|
Preventive Care
|
0% ; deductible does not apply
|
40%
|
|
Preventive Screenings
|
0% ; deductible does not apply
|
40%
|
|
Well-Child Care
|
0% ; deductible does not apply
|
40%
|
|
Immunizations
|
0% ; deductible does not apply
|
40%
|
|
Well Woman Exams
|
0% ; deductible does not apply
|
40%
|
|
Mammograms
|
0% ; deductible does not apply
|
40%
|
|
Adult Periodic Exams with Preventive Tests
|
0% ; deductible does not apply
|
40%
|
|
Inpatient Hospitalization
|
20%
|
40% subject to a benefit maximum of $600/day
|
|
Semi-Private Room & Board; Including Services and Supplies
|
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
|
|
Emergency Room
|
20%
|
20%
|
|
Urgent Care Facility
|
20%
|
40%
|
|
Prescription Drug Deductible
|
Combined with medical deductible
|
Combined with medical deductible
|
|
Prescription Drugs - Generic
|
$10
|
Not Covered
|
|
Prescription Drugs - Brand (Formulary/Preferred)
|
$30
|
Not Covered
|
|
Prescription Drugs - Brand (Non-Formulary/Non-preferred)
|
$50
|
Not Covered
|
|
Prescription Drugs - Specialty
|
$100
|
Not Covered
|
|
Prescription Drugs - Number of Days Supply
|
30 days
|
Not Covered
|
|
Prescription Drugs Mail Order - Generic
|
$20
|
Not Covered
|
|
Prescription Drugs Mail Order - Brand (Formulary/Preferred)
|
$60
|
Not Covered
|
|
Prescription Drugs Mail Order - Brand (Non-Formulary/Non-preferred)
|
$100
|
Not Covered
|
|
Prescription Drugs - Specialty (Mail Order)
|
$200
|
Not Covered
|
|
Prescription Drugs Mail Order - Number of Days Supply
|
90 days
|
Not Covered
|
|
Durable Medical Equipment & Prosthetic Devices
|
20%
|
40%
|
|
Chiropractic Services
|
20% up to 20 visits per Member, per Calendar Year
|
40% up to 20 visits per Member, per Calendar Year
|
|
Acupuncture
|
Not Covered
|
Not Covered
|
|
Outpatient Rehabilitative Physical Therapy
|
20%
|
40% subject to a benefit maximum of $350/day
|
