| |
Optimum Plans |
Annual Deductible
Individual deductible/Family Deductible |
Optimum 500 - $500/$1,500 |
Optimum 1000 - $1,000/$3,000 |
Optimum 2500 - $2,500/$7,500 |
Optimum 5000 - $5,000/$15,000 |
Optimum 10000 - $10,000/$30,000 |
Annual Out-of-Pocket Maximum
Individual out-of-pocket maximum/
Family out-of-pocket maximum |
$2,500/$7,500 |
| Lifetime Maximum |
$2 million per person
(up to $25,000 of total amount of benefits paid will be restored to Lifetime Maximum every calendar year) |
| Accidental Injury Benefit |
The deductible is waived for all covered
services, except for chiropractic services, required to treat an accidental
injury within 90 days of injury. |
|
After meeting your deductible, you pay the following
amounts for covered services:
(The deductible is waived for some covered services. These services are marked with †. |
| Preventive Care |
In-Plan |
Out-of-Plan |
| Periodic health exams, well-baby care |
$20 copay† |
40% † |
| Women's annual gynecological exam |
$20 copay † |
40% † |
| Follow-up visits after annual gynecological exam |
$20 copay † |
40% † |
| Mammograms |
$20 copay † |
40% † |
|
Physician/Provider Services |
| Office visits to a personal physician/provider |
$20 copay † |
40% † |
| Office visits to specialists |
$20 copay † |
40% † |
| Other services, including inpatient hospital visits |
20% |
40% |
| Routine immunizations/shots |
$20 copay † |
40% † |
| Hospital Services |
| Acute care |
20% |
40% |
| Skilled nursing facility |
20% |
40% |
| Maternity Care |
| Provider & hospital services |
20% |
40% |
| Emergent/Urgent care |
| Emergency services |
$125 copay |
| Urgent care services |
20% † |
Ambulance services
(see limitations) |
20% |
| Other Covered Services |
Durable medical equipment & medical supplies
(see limitations) |
20% |
40% |
Rehabilitative care & services
(see limitations) |
20% |
40% |
Laboratory & x-ray
Outpatient surgery, Radiation therapy, Chemotherapy |
20% |
40% |
Home health care
(see limitations) |
20% |
40% |
Mental health and alcohol treatment
(see limitations) |
20% |
40% |
| Prescription Drugs |
| Covered at participating retail and mail-order pharmacies
only |
Generic drugs - $10 †
Brand-name drugs
(up to a 30-day supply) - 50% † |
| A 90-day supply of certain maintenance
drugs may be purchased at a participating mail order pharmacy. |
Plan Updates 
