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Annual Deductible : |
$500 single/$1,000 family max |
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Coinsurance : |
You pay 30% (after deductible) |
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Annual Out-of-Pocket Maximum (includes deductible) : |
$3,000 single/$6,000 family max |
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Lifetime Maximum : |
$7 milllion per member |
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Office Visits : |
You pay $30 copay up to 3 visits, then 30% (after deductible) |
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Professional Service Includes X-ray and lab charges : |
You pay 30% (after deductible) |
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Emergency Care : |
You pay 30% (after deductible) |
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Ambulance : |
You pay 30% (after deductible), $3,000 maximum for ground services, no maximum for air services |
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Hospital Inpatient Services : |
You pay 30% (after deductible) |
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Outpatient Services : |
You pay 30% (after deductible) |
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Preventive Care- Children : |
You pay 30% (after deductible) for age-appropriate visits and routing immunizations (up to age 13) |
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Preventive Care- Adult : |
You pay 30% (after deductible) for mammogram screening and prostate screening |
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Prescription Drug Benefits : |
You pay $15 or 40%, whichever is greater |
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Maternity : |
Not Covered |
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Additional Services : |
You pay $30 copay for the first three office visits before the deductible. Each family member has an individual deductible and out-of-pocket maximum. The family maximum can be satisfied by 2 or more members. |
