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Plan Type : |
Health Savings Account Compatible |
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Financial/Tax Incentive : |
Yes |
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Annual Deductible : |
$2500 single/$5000 family in-network $5000 single/$10000 family out-of-network |
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Coinsurance : |
You pay 0% in-network/30% out-of-network |
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Annual Out-of-Pocket Maximum (includes deductible) : |
$2500 single/$5000 family in-network $7500 single/$15000 family out-of-network |
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Lifetime Maximum : |
$5 million |
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Office Visits : |
After deductible, You pay 0% in-network/30% out-of-network |
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Professional Service Includes X-ray and lab charges : |
After deductible, You pay 0% in-network/30% out-of-network |
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Emergency Care : |
After deductible, You pay 0% in network/0% out-of-network. |
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Ambulance : |
After deductible, You pay 0% in network/0% out-of-network. |
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Hospital Inpatient Services : |
After deductible, You pay 0% in-network/30% out-of-network |
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Outpatient Services : |
After deductible, You pay 0% in-network/30% out-of-network |
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Preventive Care- Children : |
You pay 0% deductible waived in-network/30% out-of-network. |
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Preventive Care- Adult : |
You pay 0% deductible waived in-network/30% out-of-network. |
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Prescription Drug Benefits : |
After deductible, You pay 0% in-network/30% out-of-network |
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Maternity : |
Benefits are paid for complications of pregnancy only, Routine maternity care is not covered. |
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Additinal Services |
After deductible, You pay 0% in-network/30% out-of-network |
