amount you pay toward covered expenses before the plan pays any benefits. The family deductible maximum is two times the deductible and is met collectively by two or more people
percentage of covered expenses the plan pays after you meet the deductible
percentage of covered expenses you pay after you meet the deductible
|Total out-of-pocket maximum
after you have paid this amount, which includes the deductible, the plan pays 100% of covered expenses. The family out-of-pocket maximum is two times the out-of-pocket maximum and is met collectively by two or more people
|Office visit copay
one copay covers office visits, including examination, consultation, evaluation, treatment plan development and allergy shots
|$35 copay for each of four network office visits per person; additional visits covered subject to deductible and coinsurance|
|Accident Medical Expense benefit||Up to $2,000 covered per accident or injury, before deductible and coinsurance|
|Preventive services||Immediate coverage paid at 100% for preventive services mandated by the Patient Protection and Affordable Care Act
(see ahrq.gov/clinic/uspstfix.htm for more information)
|Mammograms||Preventive covered at 100%; diagnostic covered subject to coinsurance; deductible waived|
your plan gives you access to network discounts on doctor and hospital bills
|Charges from a routine pregnancy that exceeds the plan’s separate $20,000 deductible are paid at 100% — even if you haven’t met the plan deductible|
|Complications of pregnancy
includes emergency Cesarean section and any sickness associated with pregnancy except hyperemesis gravidarum
|Diagnostic imaging and laboratory services
includes x-rays, ultrasounds, CAT scans, MRIs, lab tests and interpretation
|Outpatient hospital, surgical center or urgent care facility
includes the services of the facility and supplies
|Professional ground or air ambulance
includes transport to the nearest facility equipped to provide appropriate care, not just the closest
includes the services of the facility and supplies; benefits are paid at higher network benefit percentage even if you are out of network
|Access fee: $75 copay, then subject to deductible and coinsurance; $75 copay waived if admitted to the hospital|
|Health care practitioner services
includes doctors, surgeons, assistant surgeons, anesthesiologists, physician assistants and nurses
|Outpatient physical medicine
includes physical, speech and occupational therapies; cardiac and pulmonary rehabilitation; treatment of developmental delay; massage therapy; acupuncture and chiropractic services
All subject to deductible and coinsurance
Rehabilitation: 20 visits, Chiropractic: 10 visits, Acupuncture: 10 visits
|Home health care||Up to 130 visits covered; subject to deductible and coinsurance|
includes the services of the facility such as semi-private room and board, intensive care and supplies
|Inpatient rehabilitation facility||Up to 10 days|
|Subacute rehabilitation and skilled nursing facilities||Up to 45 days|
after 12-month waiting period, includes kidney, cornea, skin, bone marrow, heart, liver, lung and other transplants when performed by network provider or designated transplant provider
|Kidney, cornea and skin transplants covered subject to deductible and coinsurance; all others covered up to $350,000 at any provider or $500,000 plus $10,000 in travel expenses at designated transplant provider|
When you use network providers, covered charges are eligible for discounts and never exceed the maximum allowable amount.
Network and Out-of-Network Services
Emergencies: Covered services are always paid at the 75% or 50% network benefit percentage — even if you are out of network — subject to the maximum allowable amount.
Non-emergencies: Covered services are subject to the out-of-network deductible, the maximum allowable amount provision, the 50%* out-of-network benefit percentage and the increased out-of-network coinsurance out-of-pocket maximum. See chart below.
Special benefits for accidental injuries — Accident Medical Expense coverage pays the first $2,000 of expenses per accident even if you haven’t met your plan deductible.
* 50% benefit percentage applies to both the 75% and 50% benefit percentage plans.
Unless otherwise noted, all deductibles, maximums and benefit amounts are applied per person and reset each January 1. Benefits listed are in network and subject to deductible and coinsurance unless otherwise noted.