Group Name

NETWORK / OUT-OF-NETWORK / DEPENDENT OUT-OF-AREA
Calendar Year Deductible / None / $500 Individual / $1,500 Family Aggregate / $250 Individual / $750 Family Aggregate
Out-of-Pocket Calendar Year Maximum / $1,000 Individual / $2,000 Family Aggregate / $2,500 Individual / $5,000 Family Aggregate (Excludes Deductible) / $1,000 Individual / $3,000 Family Aggregate (Excludes Deductible)
OFFICE VISITS
Office Visits / $10 Co-pay Per Visit / Deductible then 70/30 Coinsurance* / Deductible then 80/20 Coinsurance*
Specialist Office Visits / $25 Co-pay Per Visit / Deductible then 70/30 Coinsurance* / Deductible then 80/20 Coinsurance*
Vision Care / $25 Co-pay (1 Every 24 Mos.) / $25 Co-pay (1 Every 24 Mos.) / $25 Co-pay (1 Every 24 Mos.)
PREVENTIVE AND WELLNESS CARE (PPACA **Required Benefits)
Office Visits / No Co-pay, 100% / Deductible then 70/30 Coinsurance / 100% for Eligible Physical Exams
Lab and X-ray / No Co-pay, 100% / Deductible then 70/30 Coinsurance / Deductible then 80/20 Coinsurance*
OUTPATIENT SERVICES
Surgery Facility Charge / $100 Co-pay Per Surgery * / Deductible then 70/30 Coinsurance* / Deductible then 80/20 Coinsurance*
Professional Services / No Co-pay; 100%
INPATIENT SERVICES
Hospital / $100 Co-pay Per Day for 3 Days* / Deductible then 70/30 Coinsurance* / Deductible then 80/20 Coinsurance*
Professional Services / No Co-pay; 100% / Deductible then 70/30 Coinsurance* / Deductible then 80/20 Coinsurance*
MENTAL HEALTH and SUBSTANCE ABUSE SERVICES
Office Visit
Inpatient Facility
Inpatient Professional Services
Outpatient Facility/Professional Services / $10 Co-pay per Visit
$100 Co-pay Per Day for 3 days*
No Co-pay; 100%
No Co-pay; 100% / Deductible then 70/30 Coinsurance* / Deductible then 80/20 Coinsurance*
BENEFITS THAT REQUIRE AUTHORIZATION (does not include list of outpatient services or drugs requiring authorization)
Organ and Tissue Transplants / Covered as any other illness / Not Available / Deductible then 80/20 Coinsurance*
Skilled Nursing Facility, Home Health and Hospice / No Co-pay, 100% / Deductible then 70/30 Coinsurance* / Deductible then 80/20 Coinsurance*
OTHER COVERED SERVICES
Prescription Drug Copayments
Refer to the contract for applicable supply limitations
Retail – up to 30 day supply
Mail Order – up to 90 day supply
[Prescription Drug Deductible] / Generic / Preferred Brand / Non-Preferred Brand / Multi-Source / Injectables (available options shown below)
-Contraceptives Included -
$7/ $20/ $35/ $50/ $50 $7 / $25 / $45 / $60 / $50 $7/ $30 / $55 / $70 / $50
$21 / $60 / $105 /$150/$150 $21 / $75 / $135 /$180 / $150 $21 / $90 / $165 / $210 / $150
[$100 per Calendar Year] [$250 per Calendar Year]
Prenatal Visits and Delivery
(Opt. for Grps 14 emps. or less) / $25 Co-pay Per Pregnancy in addition to the Inpatient Hospital Co-pay for any related hospitalization / Deductible then 70/30 Coinsurance* / Deductible then 80/20 Coinsurance*
Rehabilitative Speech Therapy / $10 Co-pay / Deductible then 70/30 Coinsurance* / Deductible then 80/20 Coinsurance*
Physical and Occupational Therapy / $10 Co-pay Per Visit / Deductible then 70/30 Coinsurance* / Deductible then 80/20 Coinsurance*
X-ray & Lab / No Co-pay; 100% / Deductible then 70/30 Coinsurance* / Deductible then 80/20 Coinsurance*
Emergency Room / $150 Co-pay/Visit; Waived if Admitted / $150 Co-pay/Visit; Waived if Admitted / Deductible then 80/20 Coinsurance*
Urgent Care Center / $50 Co-pay Per Visit / Deductible then 70/30 Coinsurance* / Deductible then 80/20 Coinsurance*
Ambulance / $50 Co-pay Per Trip / Deductible then 70/30 Coinsurance* / Deductible then 80/20 Coinsurance*
Prosthetic Appliances / 80/20 Coinsurance* / Deductible then 70/30 Coinsurance* / Deductible then 80/20 Coinsurance*
Durable Medical Equipment and Orthotics / 80/20 Coinsurance* / Deductible then 70/30 Coinsurance* / Deductible then 80/20 Coinsurance*

All benefits based on allowable charges.

*Accrues to the Out of Pocket Maximum

** Patient Protection and Affordable Care Act

NOTE: This is only an outline. All benefits are subject to the terms and conditions of the Benefit Plan. In the case of a discrepancy, the Benefit Plan will prevail. Exclusions and Limitations may apply.