| ANNUAL MAXIMUM |
Unlimited |
| Member Benefits |
In-Network |
Out-of-Network |
| Individual Deductible |
$5,500 |
$11,000 |
| Family Deductible |
$11,000 |
$22,000 |
| Coinsurance (payable by employee) |
20% |
40% |
| OUT-OF-POCKET MAXIMUM |
| Individual |
$6,350 |
$12,700 |
| Family |
$12,700 |
$25,400 |
| ESSENTIAL HEALTH BENEFITS (coinsurance payable by employee after deductible) |
| Preventive Care/Screening/Immunization (if in-network, deductible is waived) |
0% |
40% |
| Physician Office Visits |
20% |
40% |
| Ambulatory Patient Services |
20% |
40% |
| Hospitalization (inpatient and outpatient) |
20% |
40% |
| Hospice |
20% |
40% |
| Mental Health and Substance Abuse/Behavioral Health |
20% |
40% |
| Maternity and Newborn Care |
20% |
40% |
| Laboratory Services |
20% |
40% |
| Rehabilitative and Habilitative Services/Devices |
20% |
40% |
| Emergency Services |
20% |
40% |
| PRESCRIPTION DRUGS (coinsurance payable by employee after the deductible) |
| Generic |
20% |
40% |
| Preferred Brand |
30% |
50% |
| Non-preferred Brand |
40% |
50% |
| Specialty |
50% |
N/A |