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In-Network Benefits
(Member Pays)
Out of Network Benefits
(Member Pays)
Annual Deductible
Individual
Family
$3,000
$6,000
$6,000
$12,000
Annual Out-of-Pocket Maximum
Individual
Family
$5,000
$10,000
$15,000
$30,000
Coinsurance (Member pays)
20%
40%
Physician Medical Service
Primary Care Physician Office Visit
Specialist Office Visit
Routine Diagnostic Lab, X-Ray in office
Non-Routine Diagnostic Services
20% after deductible
20% after deductible
20% after deductible
20% after deductible
40% after deductible
40% after deductible
40% after deductible
40% after deductible
Routine Preventive Care
$0 Copay
(Covered 100%)
40% after deductible
Emergency Room
Ambulance
$250 copay per visit
0% after deductible
$250 copay per visit
0% after deductible
Hospital/Facility Services
Inpatient Hospital Stays
Outpatient Surgery
Advanced Radiological Imaging - Outpatient
20% after deductible
20% after deductible
20% after deductible
40% after deductible
40% after deductible
40% after deductible
Medical Equipment
Durable Medical Equipment
Orthotic and Prosthetic Devices
20% after deductible
20% after deductible
40% after deductible
40% after deductible
Skilled Nursing Services
Limited to 60 days per annual benefit period
20% after deductible
40% after deductible
Home Health Services
Limited to 60 visits annual benefit period
20% after deductible
40% after deductible
Behavioral Health
Inpatient
Outpatient
20% after deductible
20% after deductible
40% after deductible
40% after deductible
Therapy Services
Limited to 30-36 visits per annual benefit period per
therapy type
20% after deductible
40% after deductible
Prescription Drug Coverage
Generic
Preferred
Non-Preferred
Home Delivery (90 day supply)
Preventive Drugs
Generic
Preferred
Non-Preferred
20% after deductible
20% after deductible
20% after deductible
20% after deductible
$10 Copay
$35 Copay
$60 Copay
Please remember that some services require prior authorization. See your benefit summary for more information.
HSA Eligible Medical Plan—Option 1