|
You
pay the % indicated after your deductible
is met, unless otherwise specified.
Benefits are subject to deductible unless
otherwise specified. |
< td>
|
Choice
25 $750 |
In-Network |
Out-Of-Network |
| Calendar
Year Deductible |
$750
Individual / $1,500 Family |
$750
Individual / $1,500 Family |
| Maximum
Annual Out of Pocket Per Individual |
$4,000
Individual / $8,000 Family (Ded. not included.
This amount is separate from Annual Max
OOP for Non-PPO Services.) |
$5,000
Individual / $10,000 Family (Ded. not included.
This amount is separate from Annual Max
OOP for PPO Services.) |
| Lifetime
Maximum Benefit |
$5,000,000 |
$5,000,000 |
| Doctor
Visits |
$30
copay |
All
charges over $25 per visit |
| Prescription
Drug Benefit |
$10
Generic $35 Flex Formulary (50% All Other
Brands, But not less than $50) |
Not
Covered |
| Outpatient
Diagnostic X-Rays, Lab Tests |
30% |
50%
(Up to $500 per day combined for MRI's,
CT Scans and PET Scans.) |
| Adult
Preventive Care |
$30
copay plus 30% up to max benefit of $300
(not subject to ded.) |
Not
Covered |
| Child
Preventive Care |
$30
copay plus 30% (not subject to ded.) |
Not
Covered |
| Outpatient
Surgery Facility |
$250
+ 30% (Pre-authorization may apply) |
$250
+ 50% (Coverage limit of $1,000 per day) |
| Emergency
Room Use |
30%
plus $100 if not Admitted |
50%
plus $100 if not Admitted |
| Ambulance
Transportation |
30% |
30% |
| Prescribed
Home Infusion Therapy & Home Health
Care |
30% |
50% |
| Outpatient
Physical Medicine |
30%
(Up to 12 visits per calendar year Chiro
& Acu combined with annual max payable
of $500 PPO, $300 Non-PPO) ($500 calendar
year max PPO and Non-PPO combined) |
50%
(Up to 12 visits per calendar year Chiro
& Acu combined with annual max payable
of $500 PPO, $300 Non-PPO) ($500 calendar
year max PPO and Non-PPO combined) |
| In-Patient
Hospital Confinement |
$250
+ 30% |
$250
+ 50% |
| Maternity |
$250
+ 30% |
$250
+ 50% |
| Inpatient
Mental Disorders, Substance Abuse and/or
Addiction |
30%
plus $250 copay (Pre-authorization applies)
(Non-PPO coverage limit of $800 per day) |
50%
plus $250 copay (Pre-authorization applies)
(Non-PPO coverage limit of $800 per day) |
| Outpatient
Mental Disorders, Substance Abuse and/or
Addiction |
30%
(Up to 20 visits per calendar year Mental
Disorders & Substance Abuse combined,
with annual max payable of $600 PPO, $300
Non-PPO) |
50%
(Up to 20 visits per calendar year Mental
Disorders & Substance Abuse combined,
with annual max payable of $600 PPO, $300
Non-PPO) |
