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 |