| Plan Design Unless otherwise noted, all deductibles, maximums and benefit amounts are applied per person and reset each January 1. Benefits are in
network and subject to deductible and coinsurance unless otherwise noted. |
Deductible
Amount you pay toward covered expenses before the plan pays benefits |
$1,500
family deductible maximum is $3,000 and is met collectively by two or more people |
Benefit Percentage
Percentage of covered expenses the plan pays after the deductible |
75% |
Coinsurance
Percentage of covered expenses you pay after the deductible |
25% |
Total Out-Of-Pocket Maximum
After this maximum is met, the plan pays 100% of covered expenses |
Individual: $9,000
Family total out-of-pocket maximum is $18,000 and is met collectively by two or more people. |
| Benefits |
| 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);
additional preventive services paid subject to deductible and coinsurance |
| Mammograms |
Preventive covered at 100%; diagnostic covered subject to coinsurance; deductible waived |
Complications of pregnancy
includes emergency Cesarean section and any sickness associated with pregnancy except hyperemesis gravidarum |
Preventive covered at 100%; diagnostic covered subject to coinsurance; deductible waived |
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 |
Diagnostic imaging and laboratory services
(includes x-rays, ultrasounds, CAT scans, MRIs, lab tests and interpretation |
Covered subject to deductible and coinsurance |
Outpatient hospital, surgical center or urgent care facility
(includes the services of the facility and supplies |
Covered subject to deductible and coinsurance |
Professional ground or air ambulance
includes transport to the nearest facility equipped to provide appropriate care, not just the closest |
Covered subject to deductible and coinsurance |
Emergency room
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 |
Covered subject to deductible and coinsurance |
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 |
| Behavioral health |
Covered subject to deductible and coinsurance |
Inpatient hospital
includes the services of the facility such as semi-private room and board, intensive care and supplies |
Covered subject to deductible and coinsurance |
| Inpatient rehabilitation facility |
Up to 10 days |
| Subacute rehabilitation and skilled nursing facilities |
Up to 45 days |
Transplants
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 |
| Outpatient Prescription Drugs |
Generic drugs: $15 copay retail, $30 copay mail order Brand drugs: 50% coinsurance retail and mail order |
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