| Plan Name |
Balance $1750 |
Balance $2500 |
Balance
$5000 |
Welcome $750 |
Welcome $2000 |
Welcome $3500 |
HealthPays $2,750/
$5,500 |
Comprehensive
OR
Catastrophic |
Comp. |
Catas. |
Catas. |
Comp. |
Catas. |
Catas. |
Catas. |
| Annual Deductible |
$1,750 per person/ $5,250 per family |
$2,500 per person/ $7,500 per family |
$5,000 per person/ $15,000 per family |
$750 per person/ $2,250 per family |
$2,000 per person/ $6,000 per family |
$3,500 per person/ $10,500 per family |
$2,750 per person/ $5,500 per family |
| Individual Out-of-Pocket Maximum |
$6,000 |
$8,000 |
$10,000 |
$4,000 |
$6,000 |
$10,000 |
$5,100 |
| Family Out-of-Pocket Maximum |
$18,000 |
$24,000 |
$30,000 |
$12,000 |
$18,000 |
$30,000 |
$10,200 |
| Out-of-Network Co-Insurance |
|
40% |
40% |
50% |
Not Covered |
Not Covered |
Not Covered |
20% |
| Lifetime Maximum |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
$2 Million |
After deductible (or applicable co-pay) is met; in-network benefits will be paid as follows by covered member: |
| Office Visits |
$30 co-pay |
$30 co-pay |
$30 co-pay |
First 5 visits $30 co-pay NO deductible; All others $30 co-pay + 20% after deductible |
First 5 visits 40% NO deductible; All others 40% after deductible |
First 5 visits you pay 50% NO deductible; All others 50% after deductible |
You pay 10% after deductible |
| Alternative Care (i.e. Acupuncture or Chiropractic) |
$30 co-pay |
$30 co-pay |
$30 co-pay |
See Office Visits |
40% after deductible |
50% after deductible |
You pay 10% after deductible |
| Preventive Care |
100% NO deductible |
100% NO deductible |
100% NO deductible |
100% NO deductible |
100% NO deductible |
100% NO deductible |
100% NO deductible |
| Outpatient Lab & X-ray |
1st $500 covered 100% then; you pay 30% after deductible |
1st $500 covered 100% then; you pay 40% after deductible |
1st $500 covered 100% then; you pay 20% after deductible |
First $500 covered in full then you pay 20% after deductible |
You pay 40% after deductible |
You pay 50% after deductible |
You pay 10% after deductible |
| ER Services (co-pay waived if admitted) |
$100 co-pay; then 30% after deductible |
$100 co-pay; then 40% after deductible |
$100 co-pay; then 50% after deductible |
$100 co-pay; then 20% after deductible |
$100 co-pay; then 40% after deductible |
$100 co-pay; then 50% after deductible |
You pay 10% after deductible |
| Hospital Services - Inpatient |
$200 per day up to 5 days then; 30% after deductible |
$100 per day up to 5 days then; 40% after deductible |
$100 per day up to 5 days then; 50% after deductible |
$500 co-pay per day up to 5 days + you pay 20% after deductible |
You pay 40% after deductible |
You pay 50% after deductible |
You pay 10% after deductible |
| Maternity Services |
You pay 30% after deductible |
Not Covered |
Not Covered |
$30 co-pay per visit + you pay 20% after deductible |
Not Covered |
Not Covered |
Not Covered |
| Prescription Drugs |
$15 co-pay generic / 40% preferred brand / 50% non-preferred brand |
Not Covered |
Not Covered |
$15 co-pay generice / 30% brand |
Not Covered |
Not Covered |
Not Covered |
| Vision Exam |
$30 co-pay |
$30 co-pay |
$30 co-pay |
$30 co-pay per visit + you pay 20% after deductible |
You pay 40% after deductible |
You pay 50% after deductible |
Not Covered |
| Vision Hardware |
Not Covered |
Not Covered |
Up to $200 |
Up to $200 NO deductible |
Up to $200 NO deductible |
Up to $200 NO deductible |
Not Covered |
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