|
You
pay the % indicated after your deductible
is met, unless otherwise specified.
Benefits are subject to deductible unless
otherwise specified. |
< td>
|
Lifestyle
4500 3 Tier Rx |
In-Network |
Out-Of-Network |
| Calendar
Year Deductible |
Individual:
$4,500 Family: $9,000 |
Individual:
$4,500 Family: $9,000 |
| Maximum
Annual Out of Pocket Per Individual |
Not
Applicable |
Individual:
$7,500 Family: $15,000 (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 |
$45
first 4 visits |
All
charges over $25 per visit |
| Prescription
Drug Benefit |
$10
Generic $35 Formulary 50% All Other Brand
(but not less than $50) |
$10
Generic $35 Formulary 50% All Other Brand
(but not less than $50) |
| Outpatient
Diagnostic X-Rays, Lab Tests |
0% |
50% |
| Adult
Preventive Care |
All
Charges over $200 per year |
Not
Covered |
| Child
Preventive Care |
0%
($200 benefit per year, not subject to ded.) |
Not
Covered |
| Outpatient
Surgery Facility |
0%
(Pre-authorization may apply) |
50%
($1,000 per day coverage limit) |
| Emergency
Room Use |
0%
($100 waived if admitted) |
50%
($100 waived if admitted) |
| Ambulance
Transportation |
0%
(pre-authorization applies for non-emergency) |
0%
(pre-authorization applies for non-emergency) |
| Prescribed
Home Infusion Therapy & Home Health
Care |
0%
($5,000 maximum per year) |
50%
($5,000 maximum per year) |
| Outpatient
Physical Medicine |
0%
(Up to 12 visits per calendar year Chiro
& Acu combined with annual max payable
of $500) |
Not
Covered |
| In-Patient
Hospital Confinement |
0%
(pre-authorization applies) |
50%
($800 per day coverage limit) |
| Maternity |
Covered
in Full after Deductible |
50% |
| Inpatient
Mental Disorders, Substance Abuse and/or
Addiction |
All
Charges over $175 per day (Pre-authorization
applies) (Lifetime max of $5,000) |
All
Charges over $175 per day (Pre-authorization
applies) (Lifetime max of $5,000) |
| Outpatient
Mental Disorders, Substance Abuse and/or
Addiction |
All
Charges over $25 per visit (Up to 20 Outpatient
visits per calendar year) |
All
Charges over $25 per visit (Up to 20 Outpatient
visits per calendar year) |
Provider
Finder