| 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. |
Integrated Deductible
amount you pay toward covered expenses before the plan pays any benefits |
Individual plan: $2,700
Family plan: $5,400 |
Benefit Percentage
percentage of covered expenses the plan pays after you meet the deductible |
80% |
Coinsurance
percentage of covered expenses you pay after you meet the deductible |
20% |
Total Out-Of-Pocket Maximum
after you have paid this amount, the plan pays 100% of covered expenses (includes deductible) |
Individual: $4,700
Family: $9,400 |
| 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 |
Covered subject to deductible and coinsurance |
Office visits
includes examination, consultation, evaluation, treatment plan development and allergy shots |
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 |
| 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 |
| Hospice care |
Covered subject to deductible and coinsurance |
Non-emergencies: Covered services are subject to the out-of-network
deductible, maximum allowable amount provision, 60% out-of-network percentage and increased out-of-network coinsurance out-of-pocket maximum.
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