| |
|
Annual Deductibles 
|
|
Individual |
$500 |
Family |
$1,500 |
Annual Out of Pocket Maximums
|
Individual |
$3,500 |
Family |
$10,500 |
Pre-Existing Condition Limitation
|
$1,000 limit first year |
Benefit Maximums
|
|
Lifetime |
$1,000,000/person (In-and-Out-of-Network combined) |
Chiropractic/Year |
$300/person, deductible waived |
Skilled Nursing Facility/Year |
60 consecutive days |
Wellness/Year |
$300/person, deductible waived |
Rehabilitation Therapy
[Physical, Speech or Occupational]/Year |
60 consecutive days/incident |
Outpatient Services (other than Family Planning and Mental Health/Substance Abuse
Treatment) |
Office Visits |
$15 copayment/visit |
Physical Exams [Wellness] |
$15 copayment/visit |
Well Child Care and Immunizations (Wellness) |
$15 copayment/visit |
Surgical Facility |
You pay 30% |
Lab and X-ray |
You pay 30%: included in $15 co-payment if performed in doctor's office |
Inpatient Services
|
|
Hospitilization |
You pay 30% |
Surgeon's Fees |
You pay 30% |
Lab and X-ray |
You pay 30% |
Emergency Room Care [waived if admitted] |
You pay 30% |
Durable Medical Equipment
|
You pay 30% |
Skilled Nursing Facility
|
You pay 30% |
Family Planning
|
|
Prenatal Office Visits |
$15 copayment/initial visit only |
Delivery |
You pay 30% |
Vasectomy/Tubal Ligation |
You pay 30% |
Infertility Office Visits |
You pay 30% |
Prescription Drugs |
|
Mental Health and Substance Abuse Treatment Annual Deductibles
|
Individual |
$500 |
Family |
$1,500 |
Annual Out-Of-Pocket Maximum
|
$3,500/person |
Benefit Maximums, Mental Health
|
Lifetime |
Counts towards Medical Lifetime Benefit Maximum |
Inpatient Treatment |
30 days/year |
Benefit Maximums, Substance Abuse
|
Annual |
$20,000/person |
Lifetime |
$25,000/person |
Inpatient Treatment |
30 days/year |
Mental Health Treatment
|
Inpatient Treatment |
You pay 30% |
Outpatient Treatment
(up to 30 visits/year) |
$25 per visit with no deductible |
Substance Abuse Treatment
|
Inpatient Treatment |
You pay 30% |
Outpatient Treatment |
You pay 30% |
