| Lifetime
Maximum |
In-Network
|
$5,000,000.00 |
Out-of-Network
|
$5,000,000.00 |
| Out
of Pocket Maximum |
In-Network
|
$7,500.00 In and Out of Network
Combined |
Out-of-Network
|
$7,500.00 In and Out of Network
Combined |
| Annual
Deductible |
In-Network
|
$0 |
Out-of-Network
|
$0 |
| Office
Visits |
In-Network
|
$40 CoPay |
Out-of-Network
|
50% of negotiated fee plus 100% of
charges in excess of negotiated fee 1 |
Professional
Services
|
In-Network
|
40% of negotiated fee |
Out-of-Network
|
50% of negotiated fee plus 100% of
charges in excess of of negotiated fee |
| Inpatient
Hospital Services (Includes organ and tissue transplants) |
In-Network
|
40% of negotiated fee plus $400
copay per day/4 day max per admission 2,4,5 |
Out-of-Network
|
All charges except $650 per day |
| Outpatient
Hospital Services/Ambulatory Surgical Center |
In-Network
|
40% of negotiated fee plus $400
copay per outpatient surgery admit 2,4,5 |
Out-of-Network
|
All charges except $380 per day |
| Emergency
Care |
In-Network
|
40% of negotiated fee 3,5 |
Out-of-Network
|
40% of C&R for first 48 hours
plus 100% of charges in excess of C&R. After 48 hours all
charges in excess of $650 per day 3,5 |
| Maternity |
In-Network
|
Not Covered |
Out-of-Network
|
Not Covered |
| Preventive
Care/HealthyCheck Center |
In-Network
|
$25 or $75 option |
Out-of-Network
|
Not covered |
Preventive
Care
|
In-Network
|
$40 office visit plus 40% of
negotiated fee for well-baby and well-child thru age 6
$40 office visit plus 40% of negotiated fee for Covered Services
other than the Office Visit for Annual Pap exam Breast exams
Mammogram testing and appropriate screeni |
Out-of-Network
|
All charges in excess of 50% of
negotiated fee for well-baby and well-child thru age 6
All Charges in excess of 50% of negotiated fee |
| Ambulance
Service |
In-Network
|
40% of negotiated fee |
Out-of-Network
|
All charges in excess of 50% of
negotiated fee |
| Physical
Therapy, Occupational Therapy/Chiro |
In-Network
|
40% of negotiated fee; limited to 12
visits/year, participating and non-participating combined |
Out-of-Network
|
All charges except $25 per visit |
| Acupuncture/Acupressure |
In-Network
|
All charges except $25 per visit;
limited to 24 visits/year, participating and non-participating
combined |
Out-of-Network
|
All charges except $25 per visit;
limited to 24 visits/year, participating and non-participating
combined |
| Prescription
Drug Benefit |
In-Network
|
Not Covered 6 |
Out-of-Network
|
Not Covered |
