General Plan Information | Tier 1 | Tier 2 |
---|---|---|
Annual Deductible / Individual | $0.00 | $1,500 |
Annual Deductible / Family | $0.00 | $3,000 |
Coinsurance | 0% | 20% |
Maximum Out Of Pocket / Individual | $2,500 | $4,500 |
Maximum Out Of Pocket / Family | $5,000 | $9,000 |
Outpatient Services | Tier 1 | Tier 2 |
---|---|---|
Diagnostic X-Ray and Lab Test |
|
|
Preventive Services | Tier 1 | Tier 2 |
---|---|---|
Well-Child Care | Covered 100% | Covered 100% |
Pediatric Dental | Not Covered | Not Covered |
Pediatric Vision | $15.00 Copay | $30.00 Copay |
Immunizations | Covered 100% | Covered 100% |
Adult Periodic Exam with Preventive Tests | Covered 100% | Covered 100% |
Maternity Care | Tier 1 | Tier 2 |
---|---|---|
Pregnancy and Maternity Care (Pre-natal Care) |
|
20% Coinsurance after deductible |
Inpatient Hospital Services | Tier 1 | Tier 2 |
---|---|---|
Inpatient Hospitalization | $250 copay per day, max of 5 days | 20% coinsurance after deductible |
Outpatient Hospital Services | Tier 1 | Tier 2 |
---|---|---|
Outpatient Facility Charge | $100 Copay | 20% Coinsurance after deductible |
Diagnostic X-Ray and Lab Test |
$15 Copay | 20% Coinsurance after deductible |
Emergency Services | Tier 1 | Tier 2 |
---|---|---|
Outpatient Facility Charge | $100 Copay | 20% Coinsurance after deductible |
Diagnostic X-Ray and Lab Test | $15 Copay | 20% Coinsurance after deductible |
Urgent Care | Tier 1 | Tier 2 |
---|---|---|
Urgent Care Facility | $15 Copay | $30 Copay |
Mental Health / Alcohol Abuse Benefits | Tier 1 | Tier 2 |
---|---|---|
Inpatient Care | $250 Copay per day, max of 5 days | 20% coinsurance after deductible |
Outpatient Care | $15 Copay | 20% coinsurance after deductible |
General Plan Information | In-Network | Out-of-Network |
---|---|---|
Annual Deductible / Individual | $1,500 | $3,000 |
Annual Deductible / Family | $1,500 | $3,000 |
Coinsurance | 10% | 30% |
Maximum Out Of Pocket / Individual | $5,000 | $10,000 |
Maximum Out Of Pocket / Family | $10,000 | $20,000 |
Outpatient Services | In-Network | Out-of-Network |
---|---|---|
Diagnostic X-Ray and Lab Test | 10% Coinsurance after deductible | 30% Coinsurance after deductible |
Preventive Services | In-Network | Out-of-Network |
---|---|---|
Well-Child Care | Covered 100% | 30% Coinsurance, deductible does not apply |
Pediatric Dental | Not Covered | Not Covered |
Pediatric Vision | 10% Coinsurance after deductible | 30% Coinsurance for office visit, after deductible |
Immunizations | 10% Coinsurance after deductible | 30% Coinsurance, deductible does not apply |
Adult Periodic Exam with Preventive Tests | Covered 100% | 30% Coinsurance, deductible does not apply |
Maternity Care | In-Network | Out-of-Network |
---|---|---|
Pregnancy and Maternity Care (Pre-natal Care) |
10% Coinsurance after deductible
|
30% Coinsurance after deductible |
Inpatient Hospital Services | In-Network | Out-of-Network |
---|---|---|
Inpatient Hospitalization | 10% Coinsurance after deductible | 30% coinsurance after deductible |
Outpatient Hospital Services | In-Network | Out-of-Network |
---|---|---|
Outpatient Facility Charge | 10% Coinsurance after deductible | 30% Coinsurance after deductible |
Diagnostic X-Ray and Lab Test |
10% Coinsurance after deductible | 30% Coinsurance after deductible |
Emergency Services | In-Network | Out-of-Network |
---|---|---|
Outpatient Facility Charge | 10% Coinsurance after deductible | 30% Coinsurance after deductible |
Diagnostic X-Ray and Lab Test | 10% Coinsurance after deductible | 30% Coinsurance after deductible |
Urgent Care | In-Network | Out-of-Network |
---|---|---|
Urgent Care Facility | 10% Coinsurance after deductible | 30% coinsurance after deductible |
Mental Health / Alcohol Abuse Benefits | In-Network | Out-of-Network |
---|---|---|
Inpatient Care | 10% Coinsurance after deductible | 30% coinsurance after deductible |
Outpatient Care | 10% Coinsurance after deductible | 30% coinsurance after deductible |