| 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 |
