This is only a summary of the benefits under Base Coverage. It does not provide all details and provisions of the Plan. Some limitations and exclusions apply and can be found within this Plan Document. All benefits are subject to the calendar year deductible unless otherwise noted in the Covered Services section. There are two tiers of coverage: Individual and Family.
Coverage Type | Network | Out-of-Network |
|---|---|---|
Individual Coverage | ||
Calendar Year Deductible | $1,800 | $3,600 |
Preventive Medications | $75 | N/A |
Coinsurance Maximum | $3,000 | $4,000 |
Out-of-Pocket Limit | $6,500 | N/A |
Family Coverage | ||
Calendar Year Deductible | $3,200 | $6,400 |
Preventive Medications | $75 | N/A |
Coinsurance Maximum | $5,500 | $7,500 |
Out-of-Pocket Limit | $13,000 | N/A |
Telehealth Services | ||
Minor Medical | You pay $10 copayment, subject to deductible | Not Covered |
Dietitian | You pay $10 copayment, subject to deductible | Not Covered |
Mental Health | You pay 20% | Not Covered |
Other Services | ||
Specialist/Health Care | You pay 20% | You pay 40% |
Inpatient Hospital | You pay 20% | You pay 40% |
Outpatient Hospital Services | You pay 20% | You pay 40% |
Emergency Room Services | You pay 20% | You pay 20% |
X-Rays, Laboratory | You pay 20% | You pay 40% |
MRI/MRA/CAT/CTA Scans | You pay 20% | You pay 40% |
Wellness/Preventive Care | ||
Adult Wellness | Plan pays 100% | Not Covered |
Well-Newborn Nursery Care | Plan pays 100% | Not Covered |
Well-Child Office Visits and Routine Tests | Plan pays 100% | Not Covered |
Well-Child Routine Immunizations | Plan pays 100% | Not Covered |
Maternity and Chiropractic Services | ||
Maternity (Hospital, Other Services) | You pay 20% | You pay 40% |
Chiropractic Services (up to 30 visits/year) | You pay 20% | You pay 40% |
Dental and TMJ Services | ||
Accidental Injury to Teeth/TMJ Services | You pay 20% | You pay 20% |