| Plan Name |
|
|
|
|
|
|
| Comprehensive OR Catastrophic |
Comprehensive |
Catastrophic |
Catastrophic |
Catastrophic |
Catastrophic |
Catastrophic |
| Annual Deductible |
$1,000 individual /$3,000 family |
Option A: $2,500 individual/$7,500 family
Option B: $5,000 individual/$15,000 family |
$2,500 individual/$7,500 family |
Option A: $5,000 individual/$15,000 family
Option B: $7,500 individual/$22,500 family |
Option A: $2,000 individual/$4,000
Option B: $3,500 individual/$7,000 family |
$5,000 individual/$10,000 family |
| Individual Out-of-Pocket Maximum |
$7,500 |
Option A: $5,500
Option B: $5,500 |
$7,500 |
$7,500 |
$5,000 (includes deductible) |
$5,000 (includes deductible) |
| Family Out-of-Pocket Maximum |
$22,500 |
Option A: $16,500
Option B: $16,500 |
$22,500 |
$22,500 |
$10,000 (includes deductible) |
$10,000 (includes deductible) |
| Out-of-Network Co-Insurance |
50% |
50% |
50% |
50% |
50% |
50% |
| Lifetime Maximum |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
After the deductible (or aplicable co-pay) is met; category 1 & 2 benefits will be paid as follows by covered member: |
| Office Visits |
First 4 visits you pay $25 NO deductible; All others $25 + 20% after deductible |
First 4 visits you pay $25 NO deductible; All others 20% after deductible |
First 4 visits you pay $35 NO deductible; All others 30% after deductible |
First 4 visits you pay $35 NO deductible; All others 30% after deductible |
20% after deductible |
0% after deductible |
| Alternative Care (i.e. Acupuncture or Chiropractic) |
20% after deductible |
20% after deductible |
30% after deductible |
30% after deductible |
20% after deductible |
0% after deductible |
| Preventive Care |
100% NO deductible |
100% NO deductible |
100% NO deductible |
100% NO deductible |
100% NO deductible |
100% NO deductible |
| Outpatient Lab & X-ray |
100% of 1st $400; then 20% after deductible |
100% of 1st $400; then 20% after deductible |
100% of 1st $200; then 30% after deductible |
100% of 1st $200; then 30% after deductible |
20% after deductible |
0% after deductible |
| Complex Outpatient Immaging (ex. CT Scans; MRI; PET; etc…) |
50% after deductible |
50% after deductible |
50% after deductible; up to $1,500 |
50% after deductible; up to $1,500 |
50% after deductible |
0% after deductible |
| ER Services (co-pay waived if admitted) |
$100 co-pay; then 20% after deductible |
$100 co-pay; then 20% after deductible |
$150 co-pay; then 30% after deductible |
$150 co-pay; then 30% after deductible |
20% after deductible |
0% after deductible |
| Hospital Services - Inpatient |
20% after deductible |
20% after deductible |
30% after deductible |
30% after deductible |
20% after deductible |
0% after deductible |
| Maternity Services |
20% after deductible |
20% after deductible |
Not Covered |
Not Covered |
Not Covered |
Not Covered |
| Prescription Drugs |
$10 co-pay generic Rx Brand Deductible $500 then; 50%, Rx max of $2,500 |
$10 co-pay generic Rx Brand Deductible $500 then; 50%, Rx max of $2,500 |
Rx Discount Program Included |
Rx Discount Program Included |
20% after deductible (Generics Only) |
0% after deductible (Generics Only) |
| Mental Health |
20% after deductible |
20% after deductible |
30% after deductible |
30% after deductible |
20% after deductible |
0% after deductible |
| Vision Exam / Hardware |
20% up to $150 |
20% up to $150 |
Not Covered |
Not Covered |
Not Covered |
Not Covered |
| |
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