|
Individual
Family
|
$200
$400
|
$400
$800
|
|
Co-Insurance
|
80% / 20%
|
60% / 40%
|
Out-of-Pocket (including deductable)
Individual
Family
|
$1,200
$2,400
|
$2,400
$4,800
|
|
Inpatient Hospital Care
|
80% / 20%
after deductable
|
60% / 40%
after deductable
|
Emergency Room Treatment
(Limited to severe medical condition)
|
$75 co-pay
|
60% / 40%
after deductable
|
|
Outpatient Hospital Care
|
80% / 20%
after deductable
|
60% / 40%
after deductable
|
|
Office Visits
|
100%
after $15 co-pay
|
60% / 40%
after deductable
|
|
Inpatient Maternity Care
|
80% / 20%
after deductable
|
60% / 40%
after deductable
|
|
Lab and X-Ray
|
80% / 20%
after deductable
|
60% / 40%
after deductable
|
Therapy Services
(limited to 10 visits per year)
|
80% / 20%
after deductable
|
60% / 40%
after deductable
|
|
Life Insurance
|
$10,000 Term
|
|
Urgent Care
|
$25 co-pay
|
|
Lifetime Maximum
|
$2,500,000
|
Retail Prescription Drugs ($3,000 annual limit)
(30-day supply)
|
$5 generic / $15 name brand formulary
$30 name brand non-formulary
|
Mail Order Prescription Drugs
(Mandatory for prescriptions in excess of a 90-day supply)
|
$10 generic / $60 name brand formulary
$60 name brand non-formulary
|
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