| 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 |
