Individual
Family
|
$750
$1,500
|
$1,500
$3,000
|
Co-Insurance
|
90% / 10%
|
50% / 50%
|
Out-of-Pocket (including deductable)
Individual
Family
|
$2,000
$4,000
|
Unlimited
Unlimited
|
Inpatient Hospital Care
|
90% / 10%
after deductable
|
50% / 50%
after deductable
|
Emergency Room Treatment
(Limited to severe medical condition)
|
$100 co-pay
|
50% / 50%
after deductable
|
Outpatient Hospital Care
|
90% / 10%
after deductable
|
50% / 50%
after deductable
|
Office Visits
|
100%
after $20 co-pay
|
50% / 50%
after deductable
|
Inpatient Maternity Care
|
90% / 10%
after deductable
|
50% / 50%
after deductable
|
Lab and X-Ray
|
90% / 10%
after deductable
|
50% / 50%
after deductable
|
Therapy Services
(limited to 10 visits per year)
|
90% / 10%
after deductable
|
50% / 50%
after deductable
|
Life Insurance
|
$10,000 Term
|
Urgent Care
|
$40 co-pay
|
Lifetime Maximum
|
$1,000,000
|
Retail Prescription Drugs ($3,000 annual limit)
(30-day supply)
|
$20 generic / $30 name brand formulary
$45 name brand non-formulary
|
Mail Order Prescription Drugs
(Mandatory for prescriptions in excess of a 90-day supply)
|
$40 generic / $60 name brand formulary
$90 name brand non-formulary
|