APPLY
NOW |
In
Network |
Out
Of Network |
Annual
Deductible |
$5,000 |
$5,000 |
Annual
Out-Of-Pocket
Limit |
$5,000 |
$10,000 |
Lifetime
Maximum |
Unlimited |
Unlimited |
Office
Visits |
$20
(4 visit maximum
per year) |
50%
(plus all excess
charges, 4 visit
maximum per year) |
Prescription
Drugs |
$15
Generic |
50%
Drug Limited Fee
Schedule |
Laboratory
and Radiology |
No
Charge after Deductible |
50% |
Annual
Physical Exam |
No
Charge |
50% |
Annual
OB-GYN Exam |
No
Charge |
50% |
Well
Baby Care |
No
Charge |
50% |
Outpatient
Surgery |
No
Charge after Deductible |
50% |
Emergency
Room |
No
Charge after Deductible |
No
Charge after Deductible |
Ambulance |
No
Charge after Deductible |
50% |
Home
Health Care |
No
Charge after Deductible
(90 4-hour visits
per year) |
All
charges except
$75 per visit
(90 4-hour visits
per year) |
Mental
Health Services
- Outpatient |
All
charges of negotiated
fee except $25
per visit (1 visit
per day/20 visits
per year) |
All
charges of negotiated
fee except $25
per visit (1 visit
per day/20 visits
per year) |
Chiropractic
Care |
30%
(24 visits per
year) |
All
charges except
$25 per visit
(24 visits per
year) |
Acupuncture
/ Acupressure |
Not
Covered |
Not
Covered |
Inpatient
Hospital |
No
Charge after Deductible |
All
charges except
$650 per day |
Maternity
Care |
Not
Covered |
Not
Covered |
Mental
Health - Inpatient |
All
of the negotiated
fees except $175
per day (30 days
per year) |
All
of the negotiated
fees except $175
per day (30 days
per year) |
Chemical
Dependency - Inpatient |
All
of the negotiated
fees except $175
per day (30 days
per year) |
All
of the negotiated
fees except $175
per day (30 days
per year) |