| Lifetime
Maximum |
Participating Provider
|
$5,000,000/member |
Non-participating Provider
|
$5,000,000/member |
Annual
Out-of-Pocket Maximum
(includes deductible) |
Participating Provider
|
$3,000/single, $5,500/family All covered
benefits for medical and drug combined |
Non-participating Provider
|
$3,000/single, $5,500/family All covered
benefits for medical and drug combined |
| Annual
Deductible |
Participating Provider
|
$2,400/single, $4,500/family All covered
benefits for medical and drug combined |
Non-participating Provider
|
$2,400/single, $4,500/family All covered
benefits for medical and drug combined |
| Office
Visits |
Participating Provider
|
After deductible, 50% of negotiated fee |
Non-participating Provider
|
Not covered |
Professional
Services
(other office visits, X-ray, lab, anesthesia, surgeon, etc.) |
Participating Provider
|
50% of negotiated fee |
Non-participating Provider
|
Not covered |
| Hospital
Inpatient/Outpatient |
Participating Provider
|
50% of negotiated fee |
Non-participating Provider
|
Not covered |
| Emergency
Services |
Participating Provider
|
50% of negotiated fee3 |
Non-participating Provider
|
50% of customary & reasonable for first
48 hours plus 100% of excess; no coverage after 48 hours |
Maternity
(after deductible) |
Participating Provider
|
50% of negotiated fee |
Non-participating Provider
|
Not covered |
| Preventive
Care |
Participating Provider
|
HealthyCheck Centers: $25 or $75 copay for
basic screenings; routine mammogram, PSA and cancer screening, ordered
by physician: 50% of negotiated fee; well-child, 50% of negotiated fee
(deductible waived) |
Non-participating Provider
|
Not covered |
| Ambulance |
Participating Provider
|
50% of negotiated fee |
Non-participating Provider
|
Emergency only, then 50% of customary &
reasonable |
| Physical
and Occupational Therapy; Chiropractic Services |
Participating Provider
|
50% of negotiated fee limited to 12
visits/year |
Non-participating Provider
|
Not covered |
| Acupuncture/Acupressure |
Participating Provider
|
All charges except $25/visit; limited to 12
visits/year combined |
Non-participating Provider
|
Not covered |
Drug
Benefits
(retail or mail order: 30-day supply) |
Participating Provider
|
Combined with medical deductible. 15% of
negotiated fee, generic; 35% of negotiated fee, brand; 30% of negotiated
fee, self-administered injectables except insulin |
Non-participating Provider
|
Not covered |
