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| BENEFIT |
IN-NETWORK |
OUT-OF-NETWORK |
Annual Deductible Choices
(choose from 4 low-cost plans) |
$500/$1000; $1,500/$3,000
$2,500/$5,000; $5,000/$10,000 |
Single member $5,000
Family maximum $10,000 |
| Lifetime Maximum |
$7,000,000 |
Annual Out-of-Pocket Max.
(In addition to deductible) |
Single member $2,500
Family maximum $5,000 |
Single member $10,000
Family maximum $20,000 |
| Doctors' Office Visits |
30% copay for first three visits per member per year (deductible waived) and once deductible is met, then 30% of negotiated fee |
50% of negotiated fee plus all excess charges |
Professional Services
(X-ray,lab,anesthesia,surgeon,etc.) |
30% of negotiated fee |
50% of negotiated fee plus all excess charges |
Hospital Inpatient
(Overnight Hospital Stays) |
30% of negotiated fee |
All Charges except $650 per day |
Hospital Inpatient
(If You Don't Stay Overnight) |
30% of negotiated fee |
All Charges except $380 per day |
| Emergency Room Services |
30% of negotiated fee |
50% of customary and reasonable fees plus excess charges |
| Maternity |
Not covered |
| Preventive Care |
Annual physical exam(s): 30% of negotiated fee
Routine mmammogram, Pap and PSA tests: 30% of negotiated fee
Well Baby and Well Child (through age 6): 30% of negotiated fee |
Annual phyical exam(s): 50% of negotiated fee plus all exess charges
Routine mammogram, Pap and PSA tests: 50% of negotiated fee plus all excess charges
Well Baby and Well Child (through age 6): 50% of negotieated fee plus all excess charges
|
| Ambulance |
30% of negotiated fee |
50% of negotiated fee plus excess charges |
| Physical/Occupational/Speech Therapy; Chiropractic Services |
30% of negotiated fee
Plan pays up to $2,500 per year for therapy and up to $500 per year for chiropractic services |
50% of negotiated fee
plus all excess charges
Plan pays up to $2,500 per year for therapy and up to $500 per year for chiropractic services |
| Prescription Drug Coverage Options |
IN-NETWORK |
OUT-OF-NETWORK |
| SmartSense with Generic Prescription Drug Coverage (Drugs on Generic Rx Formulary only) |
Generic: $15 copay (or 40%, whichever is greater) |
Generic: $15 copay (or 40%, whichever is greater) |
| SmartSense with Comprehensive Prescription Drug Coverage (Anthem Blue Cross Formulary Drugs) |
Generic: $15 copay (or 40%, whichever is greater) $500 annual brand-name/specialty drug deductible (2 member maximum) applies before the following: Brand-name: $15 copay (or 40%, whichever is greater); 40% of negotiated fee for self-administered injectables, except insulin Specialty: 40% $4,500 annual out-of-pocket maximum (the most you will have to pay)
(in-network only and in addition to brand-name/specialty drug deductible) |
Generic: $15 copay (or 40%, whichever is greater) $500 annual brand-name/specialty drug deductible applies before the following: Brand-name: $15 copay (or 40%, whichever is greater); 40% of negotiated fee for self-administered injectables, except insulin Specialty: not covered |
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