|
|
|
|
Individual Plan Deductibles
|
| Click Here for Details |
$500
|
$1000
|
$1500
|
$2500
|
$5000
|
$1500
|
$2500
80% / 100%
|
$5000
|
|
Annual In-Network Benefits |
|
HSA-Compatible
|
No
|
No
|
No
|
No
|
No
|
Yes
|
Yes
|
Yes
|
|
Copays
|
$25/$50
|
$25/$50
|
$25/$50
|
$25/$50
|
$25/$50
|
N/A
|
N/A
|
N/A
|
|
Coinsurance
|
20%
|
20%
|
20%
|
20%
|
0%
|
20%
|
20% / 0%
|
0%
|
|
Coinsurance Maximum
|
$2000
|
$2000
|
$2000
|
$2000
|
$0
|
$2000 |
$2000 / $0 |
$0 |
|
Maternity Option* |
Yes |
Yes |
Yes |
Yes |
Yes |
N/A |
N/A |
N/A |
|
Prescription Coverage by Express Scripts, Inc. |
Retail: $0/$10/$40/$80
Mail Order $0/$20/$100/$20 |
Subject to deductible
Network discounts |
|
Preventive Care |
Deductible waived for all well child visits, women's health care (GYN exam, PAP,
Mammogram)
and the first $500 of routine screenings |
|
Emergency Care |
$150 ER copay (waived if admitted):
Subject to deductible and coinsurance
|
Subject to deductible and coinsurance
|
|
Urgent Care |
$50 copay; Not subject to deductible
|
Subject to deductible and coinsurance
|
|
Ambulance |
Subject to deductible and coinsurance |
