| Medical Benefits |
Deluxe Plan |
Standard Plan |
Economy Plan |
| Deductible |
• $100 Individual
• $300 Family |
• $250 Individual
• $600 Family |
• $500 Individual
• $1,500 Family |
Annual Out-of-Pocket
Maximum
(does not include deductible) |
• $400/person
• $800/family
|
• $750/person
• $1,500/family
• Out-of-network charges do
not accrue toward the out-of-pocket maximum |
• $3,000/person
• $6,000/family
• Out-of-network charges do
not accrue toward the
out-of-pocket maximum |
| Coinsurance (the percent the Plan pays) for most services |
• 80% after deductible
• No network provisions |
• In-network: 80% after deductible
• Out-of-network: 60% after deductible |
| Lifetime Maximum |
$2,000,000 |
Hospital Admissions
(In-patient) |
• All charges are first subject to the deductible and maximum out-of-pocket
• 100% |
• All charges are first subject to the deductible and maximum out-of-pocket
• In-network: 80% to maximum out-of-pocket
• Out-of-network: 60% Charges do not accrue toward maximum out-of-pocket |
| Emergency Room Co-Payment |
80% as other expenses, after deductible |
Outpatient Surgery, Pre-op Testing,
Second Surgical Opinions |
80% as other expenses, after deductible |
• In-network: 80% as other expenses, after deductible
• Out-of-network: 60%
• Charges do not accrue toward maximum out-of-pocket |
| Lab
and X-ray |
80% as other expenses, after deductible |
| Mental Health |
25-day in-patient
52 visits out-patient |
| Chemical Dependency |
80% as other expenses, after deductible to a maximum of $10,000 per year |
| Chiropractics |
• 80% as other expenses, after deductible
• Maximum of 26 visits per year |
| Bariatric Surgery |
$25,000 lifetime maximum |
Not covered |
| Orthognathic Surgery |
$25,000 lifetime maximum |
Not covered |
| Well Baby and Well Child Checkups |
• Under age 1: six physical exams including immunizations at 100% with no deductible
• Over age 1: see general preventive benefits
|
General Preventive Benefit
(Physical Benefit) |
• Up to $750 per person per year toward preventive-related medical services, covered at 100% with no deductible
• Includes annual physical benefits |
| Adult Immunizations |
Covered under preventive benefit with no age limit |
