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In-Network Benefits
(Member Pays)
Out of Network Benefits
(Member Pays)
Annual Deductible
Individual
Family
$4,500
$9,000
$9,000
$18,000
Annual Out-of-Pocket Maximum
Individual
Family
$6,000
$12,000
$18,000
$36,000
Coinsurance (Member pays)
30%
50%
Physician Medical Service
Primary Care Physician Office Visit
Specialist Office Visit
Routine Diagnostic Lab, X-Ray in office
Non-Routine Diagnostic Services
$30 Copay
$50 Copay
No additional copayment
30% after deductible
50% after deductible
50% after deductible
50% after deductible
50% after deductible
Routine Preventive Care
$0 Copay
(Covered 100%)
50% after deductible
Emergency Room
Ambulance
$250 Copay
30% after deductible
$250 Copay
50% after deductible
Hospital/Facility Services
Inpatient Hospital Stays
Outpatient Surgery
Advanced Radiological Imaging - Outpatient
30% after deductible
30% after deductible
30% after deductible
50% after deductible
50% after deductible
50% after deductible
Medical Equipment
Durable Medical Equipment
Orthotic and Prosthetic Devices
30% after deductible
30% after deductible
50% after deductible
50% after deductible
Skilled Nursing Services
Limited to 60 days per year
30% after deductible
50% after deductible
Home Health Services
Limited to 60 visits per year
30% after deductible
50% after deductible
Behavioral Health
Inpatient
Outpatient—Physician's Office
30% after deductible
$30 Copay
50% after deductible
50% after deductible
Therapy Services
Limited to 30-36 visits per annual benefit period per
therapy type
30% after deductible
50% after deductible
Prescription Drug Coverage
Tier 1
Tier 2
Tier 3
Home Delivery (90 day supply)
$10 copay per 30-day supply
$75 copay per 30-day supply
$150 copay per 30-day supply
3 times normal copay
Please remember that some services require prior authorization. See your benefit summary for more information.
Medical Plan—Option 2