| Copay |
$30 |
N/A |
| OfficeVisit |
Physician Office Visit (You pay deductible and/or coinsurance for other services during a physician office visit): $30 |
Physician Office Visits (You pay deductible and/or coinsurance for other services during a physician office visit): 50% |
| Deductible |
|
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| Coinsurance |
80% |
50% |
| Coinsurance Limit |
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| Out-of-Pocket Maximum |
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| Lifetime Maximum |
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| Prescription Drugs |
You pay $15 copayment per prescription for generics. Brand-name prescriptions require separate $5,000 deductible, and then you pay a $30 copayment per prescription. The smoking cessation drug Chantix is limited to a 30-day supply at one time and a 90-day supply per person per benefit period. |
You pay $15 copayment per prescription for generics. Brand-name prescriptions require separate $5,000 deductible, and then you pay a $30 copayment per prescription. The smoking cessation drug Chantix is limited to a 30-day supply at one time and a 90-day supply per person per benefit period. |
| Emergency Room |
Emergency Room: 80% of the allowed amount for covered services after meeting you deductible; Ambulance Transportation Services: 80% of the allowed amount for covered services after meeting your deductible |
Emergency Room: 50% of the allowed amount for covered services after meeting you deductible; Ambulance Transportation Services: 50% of the allowed amount for covered services after meeting your deductible |
| Adult Preventative Care |
Preventive Care Services: Nothing for services specifically listed up to $500 - for services in excess of $500 you pay your deductible and coinsurance; Immunizations: Nothing for specifically listed immunizations; Allergy Injections (Copayment applies when allergy injections is the only service provided during visit): $5 copayment per injection |
Preventive Care Services: 50% of the allowed amount for covered services after meeting your deductible; Immunizations: 50% of the allowed amount for covered services after meeting your deductible; Allergy Injections (Copayment applies when allergy injections is the only service provided during visit): 50% of the allowed amount for covered services after meeting your deductible |
| Child Preventative Care |
Preventive Care Services: Nothing for services specifically listed up to $500 - for services in excess of $500 you pay your deductible and coinsurance; Immunizations: Nothing for specifically listed immunizations; Allergy Injections (Copayment applies when allergy injections is the only service provided during visit): $5 copayment per injection |
Preventive Care Services: 50% of the allowed amount for covered services after meeting your deductible; Immunizations: 50% of the allowed amount for covered services after meeting your deductible; Allergy Injections (Copayment applies when allergy injections is the only service provided during visit): 50% of the allowed amount for covered services after meeting your deductible |
| Lab / X-Ray |
Diagnostic Laboratory and X-ray Services: 80% of the allowed amount for covered services after meeting your deductible |
Diagnostic Laboratory and X-ray Services: 50% of the allowed amount for covered services after meeting your deductible |
| Maternity |
Pregnancy Services (A separate $5,000 deductible applies, except in cases of involuntary complications): 80% of the allowed amount for covered services after meeting your deductible |
Pregnancy Services (A separate $5,000 deductible applies, except in cases of involuntary complications): 50% of the allowed amount for covered services after meeting your deductible |
| Physical Therapy |
Chiropractic Care Services (Limited to $800 per person, per benefit period): 80% of the allowed amount for covered services after meeting your deductible; Inpatient Physical Rehabilitation (From contracting provider only): 80% of the allowable amount for covered services after meeting your deductible; Outpatient Physical and Speech Therapy Services (Limited to $800 each per person, per benefit period): 80% of the allowable amount for covered services after meeting your deductible; Therapy Services (Therapies such as radiation, chemotherapy, renal dialysis, respiratory, inpatient occupational, enterostomal, growth hormone): 80% of the allowable amount for covered services after meeting your deductible |
Chiropractic Care Services (Limited to $800 per person, per benefit period): 50% of the allowed amount for covered services after meeting your deductible; Inpatient Physical Rehabilitation (From contracting provider only): Not covered; Outpatient Physical and Speech Therapy Services (Limited to $800 each per person, per benefit period): 50% of the allowable amount for covered services after meeting your deductible; Therapy Services (Therapies such as radiation, chemotherapy, renal dialysis, respiratory, inpatient occupational, enterostomal, growth hormone): 50% of the allowable amount for covered services after meeting your deductible |
| Home Health Care |
Hospice Services (Lifetime benefit limit of $10,000 per person, no deductible required): You pay nothing for covered services; Home Intravenous Therapy: 80% of the allowable amount for covered services after meeting your deductible; Home Health Skilled Nursing (Limited to $5,000 per person, per benefit period): 80% of the allowable amount for covered services after meeting your deductible |
Hospice Services (Lifetime benefit limit of $10,000 per person, no deductible required): Not covered; Home Intravenous Therapy: Not covered; Home Health Skilled Nursing (Limited to $5,000 per person, per benefit period): Not covered |
| Mental Health |
Psychiatric Inpatient and Outpatient Services (Limited to 8 inpatient days and 20 outpatient visits per person per benefit period): 50% of the allowed amount for covered services after meeting your deductible |
Psychiatric Inpatient and Outpatient Services (Limited to 8 inpatient days and 20 outpatient visits per person per benefit period): Not covered |
| Hospital Care |
Physician, Surgical and Medical Professional Services: 80% of the allowed amount for covered services after meeting your deductible; Hospital Services: 80% of the allowed amount for covered services after meeting your deductible |
Physician, Surgical and Medical Professional Services: 50% of the allowed amount for covered services after meeting your deductible; Hospital Services: 50% of the allowed amount for covered services after meeting your deductible |
