| Plan Name |
Balance
$1000 |
Balance
$1,500 |
Balance
$2,500 |
Balance
$5,000 |
Welcome
$500 |
Welcome
$1,750 |
HealthPays
$2,000
/ $4,000 |
Comprehensive
OR
Catastrophic |
Comp. |
Comp. |
Catas. |
Catas. |
Comp. |
Catas. |
Catas. |
| Annual Deductible |
$1,000 per person/ $3,000 per family |
$$1,500 per person/ $4,500 per family |
$2,500 per person/ $7,500 per family |
$5,000 per person/ $15,000 per family |
$500 per person/ $1,500 per family |
$1,750 per person/ $5,250 per family |
$2,000 per person/ $4,000 per family |
| Individual Out-of-Pocket Maximum |
$4,000 |
$6,000 |
$8,000 |
$10,000 |
$4,000 |
$6,000 |
$5,100 |
| Family Out-of-Pocket Maximum |
$12,000 |
$18,000 |
$24,000 |
$30,000 |
$12,000 |
$18,000 |
$10,200 |
| Lifetime Maximum |
$2 Million |
$2 Million |
$2 Million |
$2 Million |
$2 Million |
$2 Million |
$2 Million |
| Office Visits |
|
|
|
|
First 5 visits $30 co-pay NO deductible; All others $30 co-pay + 20% after deductible |
First 5 visits you pay 40% NO deductible; All others 40% after deductible |
You pay 10% after deductible |
| Alternative Care (i.e. Acupuncture or Chiropractic) |
|
|
|
|
First 5 visits $30 co-pay NO deductible; All others $30 co-pay + 20% after deductible |
First 5 visits you pay 40% NO deductible; All others 40% after deductible |
You pay 10% after deductible |
| Preventive Care |
|
|
|
|
First 5 visits $30 co-pay NO deductible; All others $30 co-pay + 20% after deductible |
40% NO deductible |
You pay 10% NO deductible |
| Outpatient Lab & X-ray |
Covered in Full |
Covered in Full |
Covered in Full |
Covered in Full |
First $500 covered in full then your pay 20% after deductible |
You pay 40% after deductible |
You pay 10% after deductible |
| Hospital Services - Inpatient |
You pay 20% after deductible |
You pay 30% after deductible |
You pay 40% after deductible |
You pay 50% after deductible |
$500 co-pay per day up to 5 days + you pay 20% after deductible |
You pay 40% after deductible |
You pay 10% after deductible |
| Maternity Services |
$30 co-pay NO deductible |
$30 co-pay NO deductible |
Not Covered |
Not Covered |
$30 co-pay per visit + you pay 20% after deductible |
Not Covered |
Not Covered |
| Prescription Drugs |
$10 co-pay generic/ 30% preferred brand/ 50% non-preferred Rx max of $3,000 |
$10 co-pay generic/ 30% preferred brand/ 50% non-preferred Rx max of $3,000 |
Not Covered |
Not Covered |
$20 co-pay generic/ $40 co-pay brand Rx max of $3,000 |
Not Covered |
Not Covered |
| Vision Exam |
$30 co-pay NO deductible |
$30 co-pay NO deductible |
$30 co-pay NO deductible |
$30 co-pay NO deductible |
$30 co-pay per visit + you pay 20% after deductible |
You pay 40% after deductible |
Not Covered |
| Vision Hardware |
Up to $200 |
Up to $200 |
Up to $200 |
Up to $200 |
Up to $200 |
Up to $200 |
Not Covered |
| |
|
|
