Plan Name |
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Comprehensive
OR
Catastrophic |
Comp. | Comp. | Comp. | Comp. | Catas. | Catas. | Catas. | Catas. | Catas. |
Annual Deductible |
$0 |
$0 |
$1,000 per person/ $3,000 per family |
$1,500 per person/ $4,500 per family |
$1,750 per person |
$2,500
per person |
$3,500
per person |
Option A: $1,750
Option B: $3,000 |
Option A: $3,500
Option B: $6,000 |
Individual Out-of-Pocket Maximum |
$9,500 |
$9,500 |
$8,500 |
$8,500 |
$5,000 |
$5,000 |
$5,000 |
Option A: $2,500
Option B: $1,750 |
N/A |
Family Out-of-Pocket Maximum |
$28,500 |
$28,500 |
$25,500 |
$25,500 |
No Maximum |
No Maximum |
No Maximum |
N/A |
Option A: $5,000 Option B: $3,500 |
Lifetime Maximum |
$2 Million |
$2 Million |
$2 Million |
$2 Million |
$2 Million |
$2 Million |
$2 Million |
$2 Million |
$2 Million |
Office Visits |
$30 co-pay |
$30 co-pay |
$30 co-pay NO deductible |
$30 co-pay NO deductible |
First 6 visits you pay 25% NO deductible; All others 25% after deductible |
First 6 visits you pay 25% NO deductible; All others 25% after deductible |
First 6 visits you pay 25% NO deductible; All others 25% after deductible |
You pay 20% after deductible |
You pay 20% after deductible |
Alternative Care (i.e. Acupuncture or Chiropractic) |
$25 co-pay |
$25 co-pay |
$25 co-pay NO deductible |
$25 co-pay NO deductible |
$25 co-pay NO deductible |
$25 co-pay NO deductible |
$25 co-pay NO deductible |
You pay 20% after deductible |
You pay 20% after deductible |
Preventive Care |
$30 co-pay |
$30 co-pay |
$30 co-pay NO deductible |
$30 co-pay NO deductible |
Shared with 6 office visits |
Shared with 6 office visits |
Shared with 6 office visits |
Covered in full up to $300 |
Covered in full up to $300 |
Outpatient Lab & X-ray |
You pay 20% |
You pay 30% |
You pay
20% after deductible |
You pay
30% after deductible |
You pay 25% NO deductible |
You pay 25% after deductible |
You pay 25% after deductible |
You pay 20% after deductible |
You pay 20% after deductible |
Hospital Services - Inpatient |
You pay 20% |
You pay 30% |
You pay
20% after deductible |
You pay
30% after deductible |
You pay 25% after deductible |
You pay 25% after deductible |
You pay 25% after deductible |
You pay 20% after deductible |
You pay 20% after deductible |
Maternity Services |
You pay 20% |
You pay 30% |
You pay
20% after deductible |
You pay
30% after deductible |
Not Covered |
Not Covered |
Not Covered |
Not Covered |
Not Covered |
Prescription Drugs |
$10 co-pay generic/ $45 co-pay preferred brand/ 50% non-preferred, Rx max of $3,000 brand ONLY |
$10 co-pay generic/ $45 co-pay preferred brand/ 50% non-preferred, Rx max of $3,000 brand ONLY |
$10 co-pay generic/ $45 co-pay preferred brand/ 50% non-preferred, Rx max of $3,000 brand ONLY |
$10 co-pay generic/ $45 co-pay preferred brand/ 50% non-preferred, Rx max of $3,000 brand ONLY |
Rx Discount Program
Included |
Rx Discount Program
Included |
Rx Discount Program
Included |
Rx Discount Program Included |
Rx Discount Program Included |
Vision Exam |
1 exam covered in full |
1 exam covered in full |
1 exam covered in full |
1 exam covered in full |
Not Covered |
Not Covered |
Not Covered |
Not Covered |
Not Covered |
Vision Hardware |
Up to $200 |
Up to $200 |
Up to $200 |
Up to $200 |
Not Covered |
Not Covered |
Not Covered |
Not Covered |
Not Covered |
| |
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