Great American Health Insurance in MISSISSIPPI – Health Plan Options

Great American — Patriot Class 1

A comparison of the Patriot Class 1 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	see brochure	see brochure
Copay	see brochure	see brochure
Deductible	see brochure	see brochure

Great American — Patriot Class 3

A comparison of the Patriot Class 3 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	see brochure	see brochure
Copay	see brochure	see brochure
Deductible	see brochure	see brochure

Great American — Patriot Class 4

A comparison of the Patriot Class 4 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	N/A	N/A
Office Visit	Doctor visit: $60/visit (Up to 5 visits on the individual plan and up to 8 vists per calendar year per family)	Doctor visit: $60/visit (Up to 5 visits on the individual plan and up to 8 vists per calendar year per family)
Copay	Doctor visit: $60/visit (Up to 5 visits on the individual plan and up to 8 vists per calendar year per family)	Doctor visit: $60/visit (Up to 5 visits on the individual plan and up to 8 vists per calendar year per family)
Deductible	N/A	N/A

Great American — Patriot Class 5

A comparison of the Patriot Class 5 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	N/A	N/A
Office Visit	Doctor visit: $70/visit (Up to 5 visits on the individual plan and up to 8 vists per calendar year per family)	Doctor visit: $70/visit (Up to 5 visits on the individual plan and up to 8 vists per calendar year per family)
Copay	Doctor visit: $70/visit (Up to 5 visits on the individual plan and up to 8 vists per calendar year per family)	Doctor visit: $70/visit (Up to 5 visits on the individual plan and up to 8 vists per calendar year per family)
Deductible	N/A	N/A

Great American — PPO 2500

A comparison of the PPO 2500 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	80% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied)	50% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied)
Office Visit	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $30 copay, deductible waived (Unlimited visits); Specialist Visit: $40 copay, deductible waived (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits)
Copay	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $30 copay, deductible waived (Unlimited visits); Specialist Visit: $40 copay, deductible waived (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits)
Deductible	Individual: $2,500, Family: $5,000	Individual: $5,000, Family: $10,000

Great American — PPO 5000

A comparison of the PPO 5000 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	80% after deductible up to out of pocket max. $0 once out of pocket max. is satisfied.	50% after deductible up to out of pocket max. $0 once out of pocket max. is satisfied.
Office Visit	Non-Specialist Office Visit: $40 copay deductible waived (unlimited visits), Specialist Visit: $50 copay deductible waived (unlimited visits).	50% after deductible (unlimited visits)
Copay	Non-Specialist Office Visit: $40 copay deductible waived (unlimited visits), Specialist Visit: $50 copay deductible waived (unlimited visits).	50% after deductible (unlimited visits)
Deductible	Individual: $5,000, Family: $10,000	Individual: $10,000, Family: $20,000

Great American — PPO Value 1500

A comparison of the PPO Value 1500 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	70% after deductible, up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied)	50% after deductible, up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied)
Office Visit	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): Visits 1-2 $30 copay, deductible waived; Visit 3+ 70% after deductible. Specialist and non-specialist share visit max(Unlimited visits); Specialist Visit: Visits 1-2 $30 copay, deductible waived; Visit 3+ 70% after deductible. Specialist and non-specialist share visit max (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 70% after deductible (Unlimited visits); Specialist Visit: 70% after deductible (Unlimited visits)
Copay	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): Visits 1-2 $30 copay, deductible waived; Visit 3+ 70% after deductible. Specialist and non-specialist share visit max(Unlimited visits); Specialist Visit: Visits 1-2 $30 copay, deductible waived; Visit 3+ 70% after deductible. Specialist and non-specialist share visit max (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 70% after deductible (Unlimited visits); Specialist Visit: 70% after deductible (Unlimited visits)
Deductible	Individual: $1,500, Family: $3,000	Individual: $3,000, Family: $6,000

Great American — PPO Value 2500

A comparison of the PPO Value 2500 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	80% after deductible up to out-of-pocket max. $0 once out-of-pocket max. is satisfied	50% after deductible up to out of pocket max. $0 once out of pocket max. is satisfied.
Office Visit	Non-Specialist Office Visits 1-5 $30 copay, deductible waived; Specialist Visits 1-5 $50 copay, deductible waived.	Non-Specialist and Specialist Office Visit: 50% after deductible (unlimited visits).
Copay	Non-Specialist Office Visits 1-5 $30 copay, deductible waived; Specialist Visits 1-5 $50 copay, deductible waived.	Non-Specialist and Specialist Office Visit: 50% after deductible (unlimited visits).
Deductible	Individual: $2,500, Family: $5,000	Individual: $5,000, Family: $10,000

Great American — PPO High Deductible 3000 (HSA Compatible)

A comparison of the PPO High Deductible 3000 (HSA Compatible) offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	100% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied)	50% after deductible up to out of pocket max. $0 once out of pocket max. is satisfied.50% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied)
Office Visit	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 100% after deductible (Unlimited visits); Specialist Visit: 100% after deductible (Includes Chiropractic Care Visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 70% after deductible (Unlimited visits); Specialist Visit: 70% after deductible (Unlimited visits)
Copay	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 100% after deductible (Unlimited visits); Specialist Visit: 100% after deductible (Includes Chiropractic Care Visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 70% after deductible (Unlimited visits); Specialist Visit: 70% after deductible (Unlimited visits)
Deductible	Individual: $3,000, Family: $6,000	Individual: $6,000, Family: $12,000

Great American — PPO High Deductible 5000 (HSA Compatible)

A comparison of the PPO High Deductible 5000 (HSA Compatible) offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	100% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied)	50% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied)
Office Visit	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 100% after deductible (Unlimited visits); Specialist Visit: 100% after deductible (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits)
Copay	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 100% after deductible (Unlimited visits); Specialist Visit: 100% after deductible (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits)
Deductible	Individual: $5,000, Family: $10,000	Individual: $10,000, Family: $20,000

Great American — Preventative and Hospital Care 1250

A comparison of the Preventative and Hospital Care 1250 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	80% after deductible	50% after deductible
Office Visit	Not Covered	Not Covered
Copay	Not Covered	Not Covered
Deductible	Individual: $1,250 Family: $2,500	Individual: $2,500, Family: $5,000

Great American — Preventative and Hospital Care 3000 (HSA Compatible)

A comparison of the Preventative and Hospital Care 3000 (HSA Compatible) offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	80% after deductible	50% after deductible
Office Visit	Not Covered	Not Covered
Copay	Not Covered	Not Covered
Deductible	Individual: $3,000, Family: $6,000	Individual: $6,000, Family: $12,000

Great American — First Dollar PPO 35

A comparison of the First Dollar PPO 35 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	65% ($0 once out-of-pocket max. is satisfied)	50% after deductible ($0 once out-of-pocket max. is satisfied)
Office Visit	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $35 copay (Unlimited visits); Specialist Visit: $45 copay (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits)
Copay	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $35 copay (Unlimited visits); Specialist Visit: $45 copay (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits)
Deductible	Individual: $0, Family: $0	Individual: $7,000, Family: $14,000

Great American — PPO 2500 with Dental

A comparison of the PPO 2500 with Dental offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	80% after deductible ($0 once out-of-pocket max. is satisfied)	50% after deductible ($0 once out-of-pocket max. is satisfied)
Office Visit	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $30 copay, deductible waived (Unlimited visits); Specialist Visit: $40 copay, deductible waived (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits)
Copay	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $30 copay, deductible waived (Unlimited visits); Specialist Visit: $40 copay, deductible waived (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits)
Deductible	Individual: $2,500, Family: $5,000	Individual: $5,000, Family: $10,000

Great American — PPO 5000 with Dental

A comparison of the PPO 5000 with Dental offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	80% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied)	50% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied)
Office Visit	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $40 copay, deductible waived (Unlimited visits); Specialist Visit: $50 copay, deductible waived (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits)
Copay	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $40 copay, deductible waived (Unlimited visits); Specialist Visit: $50 copay, deductible waived (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits)
Deductible	Individual: $5,000, Family: $10,000	Individual: $10,000, Family: $20,000

Great American — PPO Value 1500 with Dental

A comparison of the PPO Value 1500 with Dental offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	70% after deductible ($0 once out-of-pocket max. is satisfied)	50% after deductible ($0 once out-of-pocket max. is satisfied)
Office Visit	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): Visit 1-2 $30 copay, deductible waived. Visit 3+ 70% after deductible. Specialist and Non Specialist share visit max. (Unlimited visits); Specialist Visit: Visit 1-2 $30 copay, deductible waived. Visit 3+ 70% after deductible. Specialist and Non Specialist share visit max. (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits)
Copay	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): Visit 1-2 $30 copay, deductible waived. Visit 3+ 70% after deductible. Specialist and Non Specialist share visit max. (Unlimited visits); Specialist Visit: Visit 1-2 $30 copay, deductible waived. Visit 3+ 70% after deductible. Specialist and Non Specialist share visit max. (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits)
Deductible	Individual: $1,500, Family: $3,000	Individual: $3,000, Family: $6,000

Great American — PPO Value 2500 with Dental

A comparison of the PPO Value 2500 with Dental offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	70% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied)	50% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied)
Office Visit	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): Visits 1-2 $30 copay, deducible waived; Visit 3+ 70% after deductible. Spec. and non-spec share visit max (Unlimited visits); Specialist Visit: Visits 1-2 $30 copay, deducible waived; Visit 3+ 70% after deductible. Spec. and non-spec share visit max (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist: 50% after deductible (Unlimited visits)
Copay	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): Visits 1-2 $30 copay, deducible waived; Visit 3+ 70% after deductible. Spec. and non-spec share visit max (Unlimited visits); Specialist Visit: Visits 1-2 $30 copay, deducible waived; Visit 3+ 70% after deductible. Spec. and non-spec share visit max (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist: 50% after deductible (Unlimited visits)
Deductible	Individual: $2,500, Family: $5,000	Individual: $5,000, Family: $10,000

Great American — PPO High Deductible 3000 (HSA Compatible) with Dental

A comparison of the PPO High Deductible 3000 (HSA Compatible) with Dental offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	100% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied)	70% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied)
Office Visit	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $0 copay after deductible (Unlimited visits); Specialist Visit: $0 copay after deductible (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 70% after deductible (Unlimited visits); Specialist Visit: 70% after deductible (Unlimited visits)
Copay	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $0 copay after deductible (Unlimited visits); Specialist Visit: $0 copay after deductible (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 70% after deductible (Unlimited visits); Specialist Visit: 70% after deductible (Unlimited visits)
Deductible	Individual: $3,000, Family: $6,000	Individual: $6,000, Family: $12,000

Great American — PPO High Deductible 5000 (HSA Compatible) with Dental

A comparison of the PPO High Deductible 5000 (HSA Compatible) with Dental offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	100% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied)	50% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied)
Office Visit	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 100% after deductible (Unlimited visits); Specialist Visit: 100% after deductible (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits)
Copay	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 100% after deductible (Unlimited visits); Specialist Visit: 100% after deductible (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits)
Deductible	Individual: $5,000, Family: $10,000	Individual: $10,000, Family: $20,000

Great American — Preventative and Hospital Care 1250 with Dental

A comparison of the Preventative and Hospital Care 1250 with Dental offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	80% after deductible	50% after deductible
Office Visit	Not Covered	Not Covered
Copay	Not Covered	Not Covered
Deductible	Individual: $1,250 Family: $2,500	Individual: $2,500, Family: $5,000

Great American — Preventative and Hospital Care 3000 (HSA Compatible) with Dental

A comparison of the Preventative and Hospital Care 3000 (HSA Compatible) with Dental offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	80% after deductible	50% after deductible
Office Visit	Not Covered	Not Covered
Copay	Not Covered	Not Covered
Deductible	Individual: $3,000, Family: $6,000	Individual: $6,000, Family: $12,000

Great American — First Dollar PPO 35 with Dental

A comparison of the First Dollar PPO 35 with Dental offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	65% ($0 once out-of-pocket max. is satisfied)	50% after deductible ($0 once out-of-pocket max. is satisfied)
Office Visit	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $35 copay (Unlimited visits); Specialist Visit: $45 copay (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits)
Copay	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $35 copay (Unlimited visits); Specialist Visit: $45 copay (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits)
Deductible	Individual: $0, Family: $0	Individual: $7,000, Family: $14,000

Great American — Short Term Medical

A comparison of the Short Term Medical offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.
Copay	N/A	N/A
Deductible	$250	$250

Great American — Short Term Medical

A comparison of the Short Term Medical offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.
Copay	N/A	N/A
Deductible	$250	$250

Great American — Short Term Medical

A comparison of the Short Term Medical offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.
Copay	N/A	N/A
Deductible	$250	$250

Great American — Short Term Medical

A comparison of the Short Term Medical offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.
Copay	N/A	N/A
Deductible	$250	$250

Great American — Short Term Medical

A comparison of the Short Term Medical offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.
Copay	N/A	N/A
Deductible	$250	$250

Great American — Short Term Medical

A comparison of the Short Term Medical offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.
Copay	N/A	N/A
Deductible	$250	$250

Great American — Short Term Medical

A comparison of the Short Term Medical offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.
Copay	N/A	N/A
Deductible	$250	$250

Great American — Short Term Medical

A comparison of the Short Term Medical offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.
Copay	N/A	N/A
Deductible	$250	$250

Great American — Short Term Medical

A comparison of the Short Term Medical offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.
Copay	N/A	N/A
Deductible	$250	$250

Great American — Short Term Medical

A comparison of the Short Term Medical offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.
Copay	N/A	N/A
Deductible	$250	$250

Great American — Short Term Medical

A comparison of the Short Term Medical offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.
Copay	N/A	N/A
Deductible	$250	$250

Great American — Short Term Medical

A comparison of the Short Term Medical offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.	Covered for unexpected illness and injury, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.
Copay	N/A	N/A
Deductible	$250	$250

Great American — HealthSaver Limited-Benefit

A comparison of the HealthSaver Limited-Benefit offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	Covered for unexpected illnesses and accidents, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.	Covered for unexpected illnesses and accidents, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.
Copay	N/A	N/A
Deductible	$7,500	$7,500

Great American — HealthSaver Limited-Benefit

A comparison of the HealthSaver Limited-Benefit offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	Covered for unexpected illnesses and accidents, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.	Covered for unexpected illnesses and accidents, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.
Copay	N/A	N/A
Deductible	$7,500	$7,500

Great American — HealthSaver Limited-Benefit

A comparison of the HealthSaver Limited-Benefit offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	Covered for unexpected illnesses and accidents, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.	Covered for unexpected illnesses and accidents, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.
Copay	N/A	N/A
Deductible	$7,500	$7,500

Great American — HealthSaver Limited-Benefit

A comparison of the HealthSaver Limited-Benefit offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	Covered for unexpected illnesses and accidents, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.	Covered for unexpected illnesses and accidents, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.
Copay	N/A	N/A
Deductible	$7,500	$7,500

Great American — HealthSaver Limited-Benefit

A comparison of the HealthSaver Limited-Benefit offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	Covered for unexpected illnesses and accidents, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.	Covered for unexpected illnesses and accidents, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.
Copay	N/A	N/A
Deductible	$7,500	$7,500

Great American — HealthSaver Limited-Benefit

A comparison of the HealthSaver Limited-Benefit offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	Covered for unexpected illnesses and accidents, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.	Covered for unexpected illnesses and accidents, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.
Copay	N/A	N/A
Deductible	$7,500	$7,500

Great American — HealthSaver Limited-Benefit

A comparison of the HealthSaver Limited-Benefit offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	Covered for unexpected illnesses and accidents, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.	Covered for unexpected illnesses and accidents, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.
Copay	N/A	N/A
Deductible	$7,500	$7,500

Great American — HealthSaver Limited-Benefit

A comparison of the HealthSaver Limited-Benefit offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	Covered for unexpected illnesses and accidents, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.	Covered for unexpected illnesses and accidents, subject to deductible and coinsurance. 24/7 Teladoc services are included as well. See brochure for more details.
Copay	N/A	N/A
Deductible	$7,500	$7,500

Great American — Copay Saver

A comparison of the Copay Saver offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	70%	70%
Office Visit	Office Visit - History and Exam: $35 copay - no deductible, 2 visits per person per calendar year, including wellness office visits (2 Additional Visits plan enhancement available)	Office Visit - History and Exam: $35 copay - no deductible, 2 visits per person per calendar year, including wellness office visits (2 Additional Visits plan enhancement available)
Copay	see brochure	see brochure
Deductible	$1,500 (maximum 2 per family, per calendar year)	$1,500 (maximum 2 per family, per calendar year)

Great American — Copay Saver

A comparison of the Copay Saver offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	70%	70%
Office Visit	Office Visit - History and Exam: $35 copay - no deductible, 2 visits per person per calendar year, including wellness office visits (2 Additional Visits plan enhancement available)	Office Visit - History and Exam: $35 copay - no deductible, 2 visits per person per calendar year, including wellness office visits (2 Additional Visits plan enhancement available)
Copay	see brochure	see brochure
Deductible	$2,500 (maximum 2 per family, per calendar year)	$2,500 (maximum 2 per family, per calendar year)

Great American — Copay Saver

A comparison of the Copay Saver offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	70%	70%
Office Visit	Office Visit - History and Exam: $35 copay - no deductible, 2 visits per person per calendar year, including wellness office visits (2 Additional Visits plan enhancement available)	Office Visit - History and Exam: $35 copay - no deductible, 2 visits per person per calendar year, including wellness office visits (2 Additional Visits plan enhancement available)
Copay	see brochure	see brochure
Deductible	$5,000 (maximum 2 per family, per calendar year)	$5,000 (maximum 2 per family, per calendar year)

Great American — Copay Saver

A comparison of the Copay Saver offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	70%	70%
Office Visit	Office Visit - History and Exam: $35 copay - no deductible, 2 visits per person per calendar year, including wellness office visits (2 Additional Visits plan enhancement available)	Office Visit - History and Exam: $35 copay - no deductible, 2 visits per person per calendar year, including wellness office visits (2 Additional Visits plan enhancement available)
Copay	see brochure	see brochure
Deductible	$7,500 (maximum 2 per family, per calendar year)	$7,500 (maximum 2 per family, per calendar year)

Great American — Copay Saver

A comparison of the Copay Saver offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	70%	70%
Office Visit	Office Visit - History and Exam: $35 copay - no deductible, 2 visits per person per calendar year, including wellness office visits (2 Additional Visits plan enhancement available)	Office Visit - History and Exam: $35 copay - no deductible, 2 visits per person per calendar year, including wellness office visits (2 Additional Visits plan enhancement available)
Copay	see brochure	see brochure
Deductible	$10,000 (maximum 2 per family, per calendar year)	$10,000 (maximum 2 per family, per calendar year)

Great American — Single HSA 100

A comparison of the Single HSA 100 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	Office Visit - History and Exam: No charge after deductible	Office Visit - History and Exam: No charge after deductible
Copay	see brochure	see brochure
Deductible	$1,250 (one per family, per calendar year)	$1,250 (one per family, per calendar year)

Great American — Single HSA 100

A comparison of the Single HSA 100 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	Office Visit - History and Exam: No charge after deductible	Office Visit - History and Exam: No charge after deductible
Copay	see brochure	see brochure
Deductible	$2,500 (one per family, per calendar year)	$2,500 (one per family, per calendar year)

Great American — Single HSA 100

A comparison of the Single HSA 100 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	Office Visit - History and Exam: No charge after deductible	Office Visit - History and Exam: No charge after deductible
Copay	see brochure	see brochure
Deductible	$3,000 (one per family, per calendar year)	$3,000 (one per family, per calendar year)

Great American — Single HSA 100

A comparison of the Single HSA 100 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	Office Visit - History and Exam: No charge after deductible	Office Visit - History and Exam: No charge after deductible
Copay	see brochure	see brochure
Deductible	$3,500 (one per family, per calendar year)	$3,500 (one per family, per calendar year)

Great American — Single HSA 100

A comparison of the Single HSA 100 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	Office Visit - History and Exam: No charge after deductible	Office Visit - History and Exam: No charge after deductible
Copay	see brochure	see brochure
Deductible	$5,000 (one per family, per calendar year)	$5,000 (one per family, per calendar year)

Great American — Single HSA 70

A comparison of the Single HSA 70 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	70%	70%
Office Visit	Office Visit - History and Exam: You pay: 30% after deductible	Office Visit - History and Exam: You pay: 30% after deductible
Copay	see brochure	see brochure
Deductible	$1,250 (one per family, per calendar year)	$1,250 (one per family, per calendar year)

Great American — Single HSA 70

A comparison of the Single HSA 70 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	70%	70%
Office Visit	Office Visit - History and Exam: You pay: 30% after deductible	Office Visit - History and Exam: You pay: 30% after deductible
Copay	see brochure	see brochure
Deductible	$2,500 (one per family, per calendar year)	$2,500 (one per family, per calendar year)

Great American — Single HSA 70

A comparison of the Single HSA 70 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	70%	70%
Office Visit	Office Visit - History and Exam: You pay: 30% after deductible	Office Visit - History and Exam: You pay: 30% after deductible
Copay	see brochure	see brochure
Deductible	$3,000 (one per family, per calendar year)	$3,000 (one per family, per calendar year)

Great American — Single HSA 70

A comparison of the Single HSA 70 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	70%	70%
Office Visit	Office Visit - History and Exam: You pay: 30% after deductible	Office Visit - History and Exam: You pay: 30% after deductible
Copay	see brochure	see brochure
Deductible	$3,500 (one per family, per calendar year)	$3,500 (one per family, per calendar year)

Great American — Single HSA 70

A comparison of the Single HSA 70 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	70%	70%
Office Visit	Office Visit - History and Exam: You pay: 30% after deductible	Office Visit - History and Exam: You pay: 30% after deductible
Copay	see brochure	see brochure
Deductible	$5,000 (one per family, per calendar year)	$5,000 (one per family, per calendar year)

Great American — Plan 100

A comparison of the Plan 100 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	Office Visit - History and Exam: No charge after deductible	Office Visit - History and Exam: No charge after deductible
Copay	N/A	N/A
Deductible	$1,500 (maximum 2 per family, per calendar year)	$1,500 (maximum 2 per family, per calendar year)

Great American — Plan 100

A comparison of the Plan 100 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	Office Visit - History and Exam: No charge after deductible	Office Visit - History and Exam: No charge after deductible
Copay	N/A	N/A
Deductible	$2,500 (maximum 2 per family, per calendar year)	$2,500 (maximum 2 per family, per calendar year)

Great American — Plan 100

A comparison of the Plan 100 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	Office Visit - History and Exam: No charge after deductible	Office Visit - History and Exam: No charge after deductible
Copay	N/A	N/A
Deductible	$5,000 (maximum 2 per family, per calendar year)	$5,000 (maximum 2 per family, per calendar year)

Great American — Plan 100

A comparison of the Plan 100 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	Office Visit - History and Exam: No charge after deductible	Office Visit - History and Exam: No charge after deductible
Copay	N/A	N/A
Deductible	$7,500 (maximum 2 per family, per calendar year)	$7,500 (maximum 2 per family, per calendar year)

Great American — Plan 100

A comparison of the Plan 100 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	Office Visit - History and Exam: No charge after deductible	Office Visit - History and Exam: No charge after deductible
Copay	N/A	N/A
Deductible	$10,000 (maximum 2 per family, per calendar year)	$10,000 (maximum 2 per family, per calendar year)

Great American — Plan 80

A comparison of the Plan 80 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	Office Visit - History and Exam: You pay: 20% after deductible	Office Visit - History and Exam: You pay: 20% after deductible
Copay	N/A	N/A
Deductible	$1,500 (maximum 2 per family, per calendar year)	$1,500 (maximum 2 per family, per calendar year)

Great American — Plan 80

A comparison of the Plan 80 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	Office Visit - History and Exam: You pay: 20% after deductible	Office Visit - History and Exam: You pay: 20% after deductible
Copay	N/A	N/A
Deductible	$2,500 (maximum 2 per family, per calendar year)	$2,500 (maximum 2 per family, per calendar year)

Great American — Plan 80

A comparison of the Plan 80 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	Office Visit - History and Exam: You pay: 20% after deductible	Office Visit - History and Exam: You pay: 20% after deductible
Copay	N/A	N/A
Deductible	$5,000 (maximum 2 per family, per calendar year)	$5,000 (maximum 2 per family, per calendar year)

Great American — Plan 80

A comparison of the Plan 80 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	Office Visit - History and Exam: You pay: 20% after deductible	Office Visit - History and Exam: You pay: 20% after deductible
Copay	N/A	N/A
Deductible	$7,500 (maximum 2 per family, per calendar year)	$7,500 (maximum 2 per family, per calendar year)

Great American — Plan 80

A comparison of the Plan 80 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	Office Visit - History and Exam: You pay: 20% after deductible	Office Visit - History and Exam: You pay: 20% after deductible
Copay	N/A	N/A
Deductible	$10,000 (maximum 2 per family, per calendar year)	$10,000 (maximum 2 per family, per calendar year)

Great American — Saver 80

A comparison of the Saver 80 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	Office Visit - History and Exam: Not covered	Office Visit - History and Exam: Not covered
Copay	N/A	N/A
Deductible	$500 (maximum 2 per family, per calendar year)	$500 (maximum 2 per family, per calendar year)

Great American — Saver 80

A comparison of the Saver 80 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	Office Visit - History and Exam: Not covered	Office Visit - History and Exam: Not covered
Copay	N/A	N/A
Deductible	$1,000 (maximum 2 per family, per calendar year)	$1,000 (maximum 2 per family, per calendar year)

Great American — Saver 80

A comparison of the Saver 80 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	Office Visit - History and Exam: Not covered	Office Visit - History and Exam: Not covered
Copay	N/A	N/A
Deductible	$1,500 (maximum 2 per family, per calendar year)	$1,500 (maximum 2 per family, per calendar year)

Great American — Saver 80

A comparison of the Saver 80 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	Office Visit - History and Exam: Not covered	Office Visit - History and Exam: Not covered
Copay	N/A	N/A
Deductible	$2,500 (maximum 2 per family, per calendar year)	$2,500 (maximum 2 per family, per calendar year)

Great American — Saver 80

A comparison of the Saver 80 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	Office Visit - History and Exam: Not covered	Office Visit - History and Exam: Not covered
Copay	N/A	N/A
Deductible	$5,000 (maximum 2 per family, per calendar year)	$5,000 (maximum 2 per family, per calendar year)

Great American — Saver 80

A comparison of the Saver 80 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	Office Visit - History and Exam: Not covered	Office Visit - History and Exam: Not covered
Copay	N/A	N/A
Deductible	$7,500 (maximum 2 per family, per calendar year)	$7,500 (maximum 2 per family, per calendar year)

Great American — Saver 80

A comparison of the Saver 80 offered by Great American is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	Office Visit - History and Exam: Not covered	Office Visit - History and Exam: Not covered
Copay	N/A	N/A
Deductible	$10,000 (maximum 2 per family, per calendar year)	$10,000 (maximum 2 per family, per calendar year)