Individual
Family
|
$2,000
$4,000
|
$4,000
$8,000
|
Co-Insurance
|
80% / 20%
|
50% / 50%
|
Out-of-Pocket (including deductable)
Individual
Family
|
$4,000
$8,000
|
Unlimited
Unlimited
|
Inpatient Hospital Care
|
80% / 20%
after deductable
|
50% / 50%
after deductable
|
Emergency Room Treatment
(Limited to severe medical condition)
|
$150 co-pay
|
50% / 50%
after deductable
|
Outpatient Hospital Care
|
80% / 20%
after deductable
|
50% / 50%
after deductable
|
Office Visits
|
80% / 20%
after deductable
|
50% / 50%
after deductable
|
Inpatient Maternity Care
|
80% / 20%
after deductable
|
50% / 50%
after deductable
|
Lab and X-Ray
|
80% / 20%
after deductable
|
50% / 50%
after deductable
|
Therapy Services
(limited to 10 visits per year)
|
80% / 20%
after deductable
|
50% / 50%
after deductable
|
Life Insurance
|
$10,000 Term
|
Urgent Care
|
$55 co-pay
|
Lifetime Maximum
|
$1,000,000
|
Retail Prescription Drugs
|
Discount Prescription Card
|
Mail Order Prescription Drugs
|
Discount Prescription Card
|