| ANNUAL MAXIMUM |
Unlimited |
| Member Benefits |
In-Network |
Out-of-Network |
| Individual Deductible |
$6,000 |
$10,000 |
| Family Deductible |
$12,000 |
$20,000 |
| Coinsurance |
0% |
40% |
| OUT-OF-POCKET MAXIMUM PER CALENDAR YEAR |
| Per Covered Person |
$6,000 |
$11,000 |
| Family Deductible |
$12,000 |
$22,000 |
| ESSENTIAL HEALTH BENEFITS (coinsurance payable by employee after deductible) |
| Preventive Care/Screening/Immunization |
100% after deductible |
Not Covered |
| Physician Office Visits |
100% after deductible |
60% after deductible |
| Ambulatory Patient Services |
100% after deductible |
60% after deductible |
| Hospitalization (inpatient and outpatient) |
100% after deductible |
100% after deductible |
| Hospice |
100% after deductible |
60% after deductible |
| Mental Health and Substance Abuse/Behavioral Health |
100% after deductible |
60% after deductible |
| Laboratory Service |
100% after deductible |
60% after deductible |
| Rehabilitative and Habilitative Services/Devices |
100% after deductible |
60% after deductible |
| Emergency Services |
100% after deductible |
100% after deductible |
| PRESCRIPTION DRUGS |
| Generic |
100% after deductible |
Not Covered |
| Brand Name Drug |
Not Covered |
Not Covered |
| Non-preferred Brand |
Not Covered |
Not Covered |
| Specialty |
Not Covered |
Not Covered |
| Mail Order |
Not Covered |
Not Covered |