| Description of Service |
In-Network |
Out-of-Network |
| Annual Deductible |
$2,500 Individual / $5,000 Family (Aggregate) |
$5,000 Individual / $10,000 Family (Aggregate) |
| Coinsurance |
Plan pays 80% / You pay 20% (50% for Prescription Drugs) |
Plan pays 70% / You pay 30% |
Maximum Out of Pocket
(Does not include prescription drugs) |
$5,000 Individual / $10,000 Family |
$10,000 Individual / $20,000 Family |
| Lifetime Benefit Maximum |
Unlimited |
Unlimited |
| 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 |
Alcoholism
(subject to preapproval) |
Inpatient and Outpatient: Subject to in-network deductible and 20% coinsurance |
Inpatient and Outpatient: Subject to out-of-network deductible and 30% coinsurance |
Biologically Based Mental Illness
(Inpatient and outpatient) |
Subject to in-network deductible and 20% coinsurance |
Subject to out-of-network deductible and 30% coinsurance |
| Blood / Blood Products / Processing |
Subject to in-network deductible and 20% coinsurance |
Subject to out-of-network deductible and 30% coinsurance |
Durable Medical Equipment
(subject to preapproval) |
Subject to in-network deductible and 20% coinsurance |
Subject to out-of-network deductible and 30% coinsurance |
| Emergency Room |
$100 copayment (waived if admitted within 24 hours) is in addition to in-network deductible and 20% coinsurance |
$100 copayment (waived if admitted within 24 hours) is in addition to the out-of-network deductible and 30% coinsurance |
Extended Care or Rehabilitation Services
(subject to preapproval) Limited to 120 days combined |
Subject to in-network deductible and 20% coinsurance |
Subject to out-of-network deductible and 30% coinsurance |
Home Health Care
(subject to preapproval) |
Subject to in-network deductible and 20% coinsurance |
Subject to out-of-network deductible and 30% coinsurance |
Hospice Care
(subject to preapproval) |
Subject to in-network deductible and 20% coinsurance |
Subject to out-of-network deductible and 30% coinsurance |
Inpatient Hospital: Semi-Private Inpatient Services and Supplies
(subject to preapproval) |
Subject to in-network deductible and 20% coinsurance |
Subject to out-of-network deductible and 30% coinsurance |
| Lab services |
Plan pays 100% of allowance when provided by a network lab |
Subject to out-of-network deductible and 30% coinsurance |
| Maternity |
$25 copayment for initial office visit only. All other services subject to the in-network deductible and 20% coinsurance |
Subject to out-of-network deductible and 30% coinsurance |
Non-Biologically Based Mental Illness and Substance Abuse
Inpatient confinement: 30 days per calendar year. (1 inpatient day may be exchanged for 2 outpatient visits)
Outpatient: 20 visits per calendar year |
Subject to in-network deductible and 20% coinsurance |
Subject to out-of-network deductible and 30% coinsurance |
Prescription Drugs
(Does not count towards MOOP) |
Not subject to deductible
Covered at 50% coinsurance |
| Preventive Care |
Not subject to deductible and coinsurance
Maximum of $500 per individual (except newborns) per calendar year
Newborns: Maximum of $750 per calendar year up to age 1 |
Therapeutic Manipulations
Limited to 30 visits per calendar year and 2 modalities per visit |
$30 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 copayment per visit |
Subject to out-of-network deductible and 30% coinsurance |
