| |
HSA Value
|
| Services |
In Network
|
Out of Network
|
| Lifetime benefit maximum |
$2,000,000
|
$250,000
|
| Plan year deductible |
$2,800 (individual)
$5,600 (family)†
|
Out-of-pocket maximum, per person
(after deductible) |
$2,200 (individual)
$4,400 (family)
|
No maximum
|
| PREVENTIVE
CARE |
Member Responsibility
|
| |
In-Network
|
Out-of-Network
|
| Annual women's exam - pap, pelvic, breast |
50%*
|
50%
|
| Women's routine mammogram |
50%*
|
50%
|
| Well-baby care |
50%*
|
50%
|
| Routine physical exams |
50%*
|
50%
|
| Immunizations |
50%*
|
50%
|
| Professional Services |
| Office Visits |
50%
|
50%
|
Alternative care ($1,000 per plan year
limit)
Chiropractic, naturopathic and acupuncture |
50%
|
50%
|
| Maternity |
| All pre/post office visits and doctor
delivery; hospital charges |
50%
|
50%
|
| Hospital Services |
| Inpatient and outpatient surgery; room,
ancillary and physician charges; skilled nursing facility care |
50%
|
50%
|
Emergency Services
(deductible applies) |
| Urgent Care |
50%
|
50%
|
| Hospital emergency room |
50%
|
50%
|
| Ambulance |
50%
|
| Other Facilites and Services |
| X-ray & lab services; rehabilitation
servoces; medical supplies and devices; in-hospital care; home healthcare |
50%
|
50%
|
| Prescription services |
50%
|
| Accident benefit |
Paid as any other illness subject to deductible/co-insurance
|
*The plan deductible is waived for these
services.
† Family deductible applies when and individual and a spouse or one
(1) or more dependents are enrolled. Therefore, prior to benefits being
paid, the entire deductible must be met. |
Plan Updates 
