| Your annual deductible |
Options: - Option 1
In-network deductible:
$2,000 single /$4,000 family
OR
- Option 2
In-network deductible:
$4,000 single /$8,000 family
OR
- Option 3
In-network deductible:
$5,000 single /$10,000 family
|
Options: - Option 1
Out-of-network deductible:
$4,000 single /$8,000 family
OR
- Option 2
Out-of-network deductible:
$8,000 single /$16,000 family
OR
- Option 3
Out-of-network deductible:
$10,000 single /$20,000 family
|
Your deductible:
- Your deductible is a fixed amount you pay for the cost of covered services each year before the plan begins to pay for them.
- You can meet your family deductible by the expenses of one or more individuals in the family.
|
| Your coinsurance |
Plan pays: |
Plan pays: You pay: |
- Coinsurance is the percentage you and the plan each pay for covered services you receive.
- You begin paying coinsurance after you meet your out-of-network deductible each year.
|
| Annual out-of-pocket maximum |
Your in-network deductible is your in-network out-of-pocket maximum per year. |
- Option 1
$9,000 single/$18,000 family - Option 2
$13,000 single/$26,000 family - Option 3
$15,000 single/$30,000 family
|
- The most you will pay for covered services for you and your family during one plan year. It includes your deductible and coinsurance.
|
| Annual benefit maximum |
$2 million (combined in-network & out-of-network)
|
- The most the plan will pay for covered services for you and your family during one plan year.
|
Covered services |
| Benefit | In network | Out of network | Notes |
|---|
Preventive care - Office visit
- Pap smear
- Mammogram
- Prostate screening
- Preventive lab/x-ray
- Child immunizations to age 18
|
Plan pays: |
Not covered |
|
Physician services - Office visit
- Diagnostic lab/x-ray
- Allergy injections, testing, serum
- Inpatient/outpatient services
- Surgery
|
Plan pays: |
Plan pays: |
- After you meet your deductible each year, you and the plan pay coinsurance for covered services.
|
| Emergency room services |
Plan pays: |
Plan pays: |
- After you meet your deductible each year, you and the plan pay coinsurance for covered services.
|
| Outpatient lab/x-ray |
Plan pays: |
Plan pays: |
- After you meet your deductible each year, you and the plan pay coinsurance for covered services.
|
| Hospitalization |
Plan pays: |
Plan pays: |
- After you meet your deductible each year, you and the plan pay coinsurance for covered services.
|
| Benefit | In network | Out of network | Notes |
|---|
| Ambulance |
Plan pays: |
Plan pays: |
- After you meet your deductible each year, you and the plan pay coinsurance for covered services.
|
Outpatient speech therapy
Outpatient occupational therapy
Outpatient physical therapy/spinal manipulation
Cardiac rehabilitation |
Plan pays: |
Plan pays: |
- Plan pays for a maximum of 30 visits for all these therapy services combined per member each year.
- After you meet your deductible each year, you and the plan pay coinsurance for covered services.
|
Skilled nursing facility
Sub acute
Inpatient rehabilitation
Hospice |
Plan pays: |
Plan pays: |
- 60-day combined annual max per member
- After you meet your deductible each year, you and the plan pay coinsurance for covered services.
|
| Home health care |
Plan pays: |
Plan pays: |
- Plan pays for a maximum of 60 visits per member each year
- After you meet your deductible each year, you and the plan pay coinsurance for covered services.
|
| Substance abuse |
Plan pays: |
Plan pays: |
- After you meet your deductible each year, you and the plan pay coinsurance for covered services.
|
| Benefit | In network | Out of network | Notes |
|---|
| Durable medical equipment, prosthetics and orthotics |
Plan pays: |
Plan pays: |
- Plan pays a maximum per member each year of $2,000 for in-network services and $2,000 for out-of-network services.
- After you meet your deductible each year, you and the plan pay coinsurance for covered services.
|
| Dietitian services |
Plan pays: |
Plan pays: |
- Coverage for a maximum of 6 visits per member each year
- After you meet your deductible each year, you and the plan pay coinsurance for covered services.
|
| Prescription drug coverage |
Plan pays: |
Not covered |
- Includes oral contraceptives
- After you meet your deductible each year, you and the plan pay coinsurance for covered services.
|
| Medical specialty drugs |
Plan pays: |
Plan pays: |
- Plan pays a maximum per member each year of $25,000 for drugs received in-network and $25,000 for drugs received out-of-network.
- After you meet your deductible each year, you and the plan pay coinsurance for covered services.
|
|
| Transplants |
Plan pays: |
Plan pays: |
- Only services at a designated transplant facility are covered.
- After you meet your deductible each year, you and the plan pay coinsurance for covered services.
|
Pre-existing condition exclusion
This exclusion does not apply to anyone under age 19 |
- The plan does not cover, or pay coinsurance on, charges for services needed to treat a pre-existing illness, injury or condition until you have been continuously insured under the plan for 12 months, if the pre-existing condition was not disclosed on your application.
- After the 12-month waiting period, the plan pays for covered services for a pre-existing condition unless the condition is specifically excluded from coverage.
- For details see the plan policy on our Plan documents page.
|
Services not covered |
- Maternity services
- Certain surgeries: Bariatric surgery, blepharoplasty of the upper eyelids, breast reduction, orthognathic surgery, panniculectomy, surgical treatment of male gynecomastia, removal of port wine stains
- Procedures to correct obstructive sleep apnea
- Family planning and infertility services: Contraceptives, vasectomy, tubal ligation, diaphragm, infertility counseling, treatment of the underlying causes of infertility
- Treatment for temporomandibular joint disorder (TMJ)
|
Waiting periods90 days: The plan will not pay for treatment of these conditions during the first 90 days you are covered by the plan: Cystocele, enterocele, rectocele, urethrocele, uterine prolapse, inguinal hernia (other than strangulated or incarcerated), carpal tunnel syndrome, and varicose veins. Surgeries subject to the 90 day waiting period include: tonsillectomy, adenoidectomy, hysterectomy, bunionectomy, and hemorrhoidectomy |
Optional accident rider |
| Optional coverage that pays the first $1,000 for covered services needed due to accidents or injuries before you've met your deductible. |
Plan pays: - First $1,000, then base plan benefits
|
Plan pays: - First $1,000, then base plan benefits
|
|
