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 |
Unlimited |
Unlimited |
| Coinsurance |
You pay 20% coinsurance after the deductible has been met. |
You pay 0% coinsurance after the deductible has been met. |
Calendar-Year 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.) |
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. |
| Psychiatric Conditions/Substance Abuse Benefits*** |
You pay 20% coinsurance after the deductible has been met. |
You pay 0% coinsurance after the deductible has been met. |
| 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 |
You pay 0% coinsurance. Deductible does not apply. Limited to $1,400 per ear for each three-year period. |
You pay 0% coinsurance. Deductible does not apply. Limited to $1,400 per ear for each three-year period. |
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.
|