|
Solaura HSA Plan 2a Single |
In-Network |
Out-Of-Network |
|
|
Annual
Deductible |
Individual: $5,000 |
Individual: $5,000 |
|
|
Annual Out-Of-Pocket Limit
|
Individual: $5,000 |
Individual: $10,000 |
|
|
Lifetime
Maximum |
$5,000,000 |
$5,000,000 |
|
|
Office
Visits |
No Charge after Deductible |
30% |
|
|
Prescription
Drugs |
No Charge after Deductible |
30% |
|
|
Laboratory
and Radiology |
No Charge after Deductible |
30% |
|
|
Annual
Physical Exam |
No Charge |
30% |
|
|
Annual
OB-GYN Exam |
No Charge |
30% |
|
|
Well
Baby Care |
No Charge |
30% |
|
|
Outpatient
Surgery |
No Charge after Deductible |
30% |
|
|
Emergency
Room |
No Charge after Deductible |
30% |
|
|
Ambulance
|
No Charge after Deductible |
30% |
|
|
Home
Health Care |
No Charge after Deductible (60 visits per year maximum) |
30% (60 visits per year maximum) |
|
|
Mental Health Services |
$30 maximum benefit per visit up to 12 visits per year |
$30 maximum benefit per visit up to 12 visits per year |
|
|
Chiropractic
Care |
$30 maximum benefit per visit up to 12 visits per year |
$30 maximum benefit per visit up to 12 visits per year |
|
|
Acupuncture
/ Acupressure |
$30 maximum benefit per visit up to 12 visits per year |
$30 maximum benefit per visit up to 12 visits per year |
|
|
Inpatient Co-payment |
No Charge after Deductible |
30% |
|
|
Maternity
Care |
Not Covered |
Not Covered |
|
|
Inpatient Mental
Health |
$100 per day maximum benefit up to $3,000 per year |
$100 per day maximum benefit up to $3,000 per year |
|
|
Chemical Dependency
|
See Benefit Contract |
See Benefit Contract |