| Description of Service |
In-Network |
Out-of-Network |
| Annual Deductible |
N/A |
$7,500 Individual / $15,000 Family (Aggregate) |
| Coinsurance |
Applies to Prescription Drugs only. Plan pays 50% /You pay 50% |
Plan pays 70% / You pay 30% (50% for Prescription Drugs) |
Maximum Out of Pocket
(Does not include prescription drugs) |
$5,000 Individual / $10,000 Family |
$22,500 Individual / $45,000 Family |
| Lifetime Benefit Maximum |
Unlimited for most services |
Unlimited for most services |
| Primary Care Physician (PCP) |
$30 copayment per visit to selected PCP |
Subject to out-of-network deductible and 30% coinsurance |
| Specialist Services |
$50 copayment per visit |
Subject to out-of-network deductible and 30% coinsurance |
Inpatient Hospital
(Subject to preapproval) |
$300 copayment per day for maximum of 5 days per admission; $3,000 maximum per calendar year |
Subject to out-of-network deductible and 30% coinsurance |
| Outpatient Hospital |
$30 copayment |
Subject to out-of-network deductible and 30% coinsurance |
| Ambulatory Surgical Center Facility Charges |
$30 copayment |
Subject to out-of-network deductible and 30% coinsurance |
| Hospital Outpatient Surgery Facility Charges |
$60 copayment |
Subject to out-of-network deductible and 30% coinsurance |
| Emergency Room |
$100 copayment (waived if admitted within 24 hours) |
$100 copayment (waived if admitted within 24 hours) is in addition to the out-of-network deductible and 30% coinsurance |
Biologically Based Mental Illness and Alcoholism
(Inpatient is subject to preapproval) |
Inpatient: $300 copayment per day for maximum of 5 days per admission; $3,000 maximum per calendar year |
Subject to out-of-network deductible and 30% coinsurance |
| Blood / Blood Products / Processing |
Plan pays 100% |
Subject to out-of-network deductible and 30% coinsurance |
Durable Medical Equipment
(subject to preapproval) |
Plan pays 100% |
Subject to out-of-network deductible and 30% coinsurance |
Home Health Care and Hospice Care
(subject to preapproval) |
Unlimited days |
Subject to out-of-network deductible and 30% coinsurance |
| Lab services |
Plan pays 100% when provided by a network lab |
Subject to out-of-network deductible and 30% coinsurance |
| Maternity |
$25 copayment for initial office visit only; Subject to inpatient hospital copayment |
Subject to out-of-network deductible and 30% coinsurance |
Non-Biologically Based Mental Illness and Substance Abuse
Inpatient confinement: subject to preapproval, limited to 30 days per calendar year. (1 inpatient day may be exchanged for 2 outpatient visits)
Outpatient: 20 visits per calendar year |
Inpatient: 100% after the inpatient hospital copayment
Outpatient: 100% after the office visit copayment |
Subject to out-of-network deductible and 30% coinsurance |
Prescription Drugs
(Does not count towards MOOP) |
50% coinsurance |
| Preventive Care |
Office visit copayment per visit |
Not subject to out-of-network deductible and 30% coinsurance. Maximum of $500 per individual (except newborns) per calendar year. Newborns: maximum of $750 per calendar year up to age 1 |
Rehabilitation Centers
(subject to preapproval) |
Subject to inpatient hospital copayment. Waived if immediately preceded by an inpatient hospital stay |
Subject to out-of-network deductible and 30% coinsurance |
Therapeutic Manipulations
Limited to 30 visits per calendar year and 2 modalities per visit |
$30 office visit copayment per visit |
Subject to out-of-network deductible and 30% coinsurance |
Therapy Services
Cognitive rehabilitation therapy, occupational therapy, physical therapy and speech therapy are limited to 30 visits per calendar year per therapy |
$30 office visit copayment per visit |
Subject to out-of-network deductible and 30% coinsurance |
