| |
Value Plans |
Annual Deductible
Individual deductible/Family Deductible |
Value 500 - $500/$1,500 |
Value 1000 - $1,000/$3,000 |
Value 2500 - $2,500/$7,500 |
Value 5000 - $5,000/$15,000 |
Value 7500 - $7,500/$22,500 |
Annual Out-of-Pocket Maximum
Individual out-of-pocket maximum/
Family out-of-pocket maximum |
Value 500 - $4,000/$12,000 |
Value 1000 - $4,500/$13,500 |
Value 2500 - $5,500/$16,500 |
Value 5000 - $8,500/$25,500 |
Value 7500 - $11,000/$33,000 |
| 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 † |
50% † |
| Women's annual gynecological exam |
$20 copay † |
50% † |
| Follow-up visits after annual gynecological exam |
$20 copay † |
50% |
| Mammograms |
$20 copay † |
50% |
|
Physician/Provider Services |
| Office visits to a personal physician/provider |
$20 copay † |
50% † |
| Office visits to specialists |
30% |
50% |
| Other services, including inpatient hospital visits |
30% |
50% |
| Routine immunizations/shots |
$20 copay † |
50% † |
| Hospital Services |
| Acute care |
30% |
50% |
Skilled nursing facility
(see limitations) |
30% |
50% |
| Maternity Care |
| Provider & hospital services |
30% |
50% |
| Emergent/Urgent care |
| Emergency services |
$125 copay |
| Urgent care services |
30% † |
| Ambulance services |
30% |
| Other Covered Services |
| Durable medical equipment & medical supplies |
30% |
50% |
| Outpatient rehabilitative services |
30% |
50% |
Laboratory & x-ray
Outpatient surgery, Radiation therapy, Chemotherapy |
30% |
50% |
| Home health care |
30% |
50% |
| Mental health and alcohol treatment |
30% |
50% |
| Prescription Drugs |
| Covered at participating pharmacies
at the In-Plan benefit only |
Generic drugs & 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 
