| |
Maximizer
|
| Lifetime benefit maximum |
$2,000,000
($250,000 can be accessed out of network)
|
Plan year deductible, individual
(family is 3x the individual) |
$1,000 / $2,500 / $5,000
|
Out-of-pocket maximum, per
person
(after deductible) |
$5,000
|
$10,000 |
| Preventive Care |
Member Responsibility
|
| |
In-Network
|
Out-of-Network
|
| Annual women's exam - pap, pelvic, breast |
$20 co-pay*
|
50%
|
| Women's routine mammogram |
$20 co-pay*
|
50%
|
| Well-baby care |
$20 co-pay*
|
Not covered |
| Routine physical exams |
$20 co-pay*
|
Not covered
|
| Immunizations |
$0*
|
Not covered
|
| Professional Services |
| Office visits |
$20 co-pay*
|
50%
|
Alternative care ($1,000 per plan year
limit)
Chiropractic, naturopathic and acupuncture |
$20 co-pay*
|
50%
|
| Maternity |
| All pre/post office visits and doctor
delivery; hospital charges |
30%
|
50%
|
| Hospital Services |
| Inpatient and outpatient surgery; room,
ancillary and physician charges; skilled nursing facility care |
30%
|
50%
|
| Emergency Services |
| Urgent Care |
$20* co-pay
|
50%
|
Hospital emergency room
(deductible applies) |
30% after $100 copayment
|
| Ambulance |
30%
|
| Other Facilities and Services |
| Lab and X-ray services, rehabilitation
services, medical supplies and devices; in-hospital care; home healthcare |
30%
|
50%
|
| Prescription services |
$15 generics or 50% brand*; $5,000 annual maximum
|
| Accident benefit |
Deductible waived for treatment
completed within 90 days |
*The plan deductible is waived for these
services.
(The deductibles, co-payments and co-insurance percentages above represent what you pay.) |
Plan Updates 
