| Plan Feature | In-Network |
|---|---|
| Deductible Per individual, per calendar year. Maximum 2 per family) | $1,500 per individual / $3,000 per family $2,500 per individual / $7,500 per family $5,000 per individual / $15,000 per family $7,500 per individual / $15,000 per family $10,000 per individual / $20,000 per family |
| Coinsurance Choices The level of coverage provided by the plan after the calendar year Deductible has been satisfied. | You pay 30% |
| Coinsurance Out-of-Pocket Maximum The amount of money an individual pays toward covered hospital and medical expenses during any one calendar year after deductible. | Choice of $5,000 or $10,000 |
| Lifetime Maximum Benefit | Unlimited |
| Physicians (illness and injury) | |
| Office Visits Primary Care or Specialist | $35 copay – no deductible, 2 visits per person per calendar year including wellness office visits (2 additional visits plan enhancement available) |
| Wellness/Preventive Care Benefits | Covered at 100%, not subject to deductible |
| Doctor Office Visit Adult, child, in-network only. | $35 copay (no deductible) (Subject to visit limit stated above) |
| X-Ray and Lab | You pay: 30% after deductible |
| Child Immunizations | Covered at 100%, not subject to deductible |
| Preventive Mammogram, Pap Smear, PSA screening | Covered at 100%, not subject to deductible |
| Outpatient Expense Benefits | |
| X-Ray and Lab | You pay: 30% after deductible |
| Facility/Hospital for Outpatient Surgery | You pay: 30% after deductible |
| Surgeon, Assistant Surgeon, and Facility Fees Surgery in doctor’s office not covered. | You pay: 30% after deductible |
| Hemodialysis, Radiation, Chemotherapy, Organ Transplant Drugs, and CAT Scans, MRIs | You pay: 30% after deductible |
| Emergency Room Fees – Illness | You pay: $500 copay if not admitted, then 30% after deductible |
| Emergency Room Fees – Injury | You pay: $500 copay if not admitted, then 30% after deductible |
| Spine and Back Disorders CAT scan and MRI tests not subject to this limitation. | Not covered |
| Mental and Nervous Disorders Including substance abuse. | Not covered |
| Other Outpatient Expenses | Not covered |
| Inpatient Expense Benefits | |
| Room and Board, Intensive Care Unit, Operating Room, Recovery Room, Prescription Drugs, Physician Visit, and Professional Fees of Doctors, Surgeons, and Nurses | You pay: 30% after deductible |
| Other Inpatient Services | You pay: 30% after deductible |
| Prescription Drug Benefit1 | You Pay |
|---|---|
| Generic | $15 co-payment (no deductible) |
| Brand Drugs | Not covered |
| Annual Maximum Covered expense, per person per calendar year. | Not applicable |
1 Only generic drugs are covered under the Copay Saver Plan.
>READ YOUR POLICY CAREFULLY; This outline of coverage provides a brief description of the important features of the Policy. This is not the insurance contract, and only the actual Policy provisions will control. The Policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!
