| |
You
pay the % indicated after your deductible
is met, unless otherwise specified.
Benefits are subject to deductible unless
otherwise specified. |
< td>
|
Choice
Saver Select $2,400 Single |
In-Network |
Out-Of-Network |
| Calendar
Year Deductible |
$2,400 |
$2,400 |
| Maximum
Annual Out of Pocket Per Individual |
Not
Applicable |
$5,000
(This amount includes the Annual Max OOP
for Non-PPO Services.) |
| Lifetime
Maximum Benefit |
$5,000,000 |
$5,000,000 |
| Doctor
Visits |
0% |
All
charges over $25 per visit |
| Prescription
Drug Benefit |
0%
at Participating Pharmacy Using Your Medco
RX Card |
Not
Covered |
| Outpatient
Diagnostic X-Rays, Lab Tests |
0% |
50% |
| Adult
Preventive Care |
0%
(up to max benefit of $200, not subject
to ded.) |
Not
covered |
| Child
Preventive Care |
0%
(not subject to ded.) |
Not
covered |
| Outpatient
Surgery Facility |
0%
(Pre-authorization may apply) |
50% |
| Emergency
Room Use |
0% |
50% |
| Ambulance
Transportation |
0%
(pre-authorization applies for non-emergency) |
0%
(pre-authorization applies for non-emergency) |
| Prescribed
Home Infusion Therapy & Home Health
Care |
0%
(Pre-authorization applies) (up to 50
visits combined) ($5,000 max per calendar
year) |
50% |
| Outpatient
Physical Medicine |
0%
(Up to 12 visits per calendar year Chiro
& Acu combined with annual max payable
of $500) |
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 |
0%
(pre-authorization applies) |
50% |
| Maternity |
Not
Covered |
Not
Covered |
| Inpatient
Mental Disorders, Substance Abuse and/or
Addiction |
0%
(Pre-authorization applies) (Combined
lifetime max of $5,000 for Inpatient &
Outpatient services) (Up to 20 Outpatient
visits per calendar year Mental Disorders
& Substance Abuse combined, with annual
max payable of $600) |
0%
(Pre-authorization applies) (Combined
lifetime max of $5,000 for Inpatient &
Outpatient services) (Up to 20 Outpatient
visits per calendar year Mental Disorders
& Substance Abuse combined, with annual
max payable of $600) |
| Outpatient
Mental Disorders, Substance Abuse and/or
Addiction |
0%
(Combined lifetime max of $5,000 for Inpatient
& Outpatient services) (Up to 20 Outpatient
visits per calendar year, with annual
max payable of $600) |
50%
(Combined lifetime max of $5,000 for Inpatient
& Outpatient services) (Up to 20 Outpatient
visits per calendar year, with annual
max payable of $600) |
|
