| Covered Services |
In-Network |
Out-of-Network |
Calendar-Year Deductible
(Individual/Family) |
$250/$500 |
$250/$500 |
Annual Out-of-Pocket Max
Includes deductible
(Individual/Family) |
$3,000/$6,000 |
$5,500/$11,000 |
Lifetime Maximum
Physician Office Visit |
$2,000,000
$20 copay |
$2,000,000
Deductible, then 65% |
| Specialty-Care Office Visits |
|
|
Additional Routine
Preventative Care
Emergency Services |
$20 copay (deductible waived)
$500 Calendar-Year Maximum
Deductible, then 80% |
Deductible, then 65$
$500 Year maximum
Deductible, then 65% |
| In-patient Hospital Services |
Separate deductible of $150
for all pre-certified services;
or $300 for all non-pre-certified
services; then deductible,
then 80% |
Separate deductible of $150
for all pre-certified services,
then deductible, then 80% |
| Laboratory Services |
100% at LabOne facilities;
Deductible, then 80% at
non-LabOne facilities |
Deductible, then 65% |
Outpatient Surgery in Hospital
or Outpatient Facility |
Deductible, then 80% |
Deductible, then 65% |
| Accidental Injury Benefit |
Up to $500 per accident for
non-work-related injuries;
100% of usual and customary |
Up to $500 per accident for
non-work-related injuries;
100% of usual and customary |
Durable Medical Equipment
Home Health Services |
Deductible, then 80%;
Deductible, then 80%;
50-Visit Calendar Year Max |
Deductible, then 65%;
Deductible, then 65%;
50-Visit Calendar Year Max |
| Skilled Nursing |
Deductible, then 80%;
60-Day Calendar Year Maximum |
Deductible, then 65%;
60-Day Calendar Year Maximum |
Physical & Occupational
Therapy |
Deductible, then 80%;
More than 14 visits per occurence
require case management
authorization |
Deductible, then 65%;
More than 14 visits per occurence
require case management
authorization |
| Speech Therapy |
Deductible, then 80%;
All visits require case management
authorization |
Deductible, then 65%;
All visits require case management
authorization |
| Chiropractic |
Deductible, then 65%;
$600 Calendar-Year Maximum |
Deductible, then 65%;
$600 Calendar-Year Maximum |
| Outpatient Mental Illness |
Deductible, then 70% up to
25 visits per Calendar Year |
Deductible, then 45% up to
25 visits per Calendar Year |
| Outpatient Substance Abuse |
Deductible, then 70% up to
$1,500 per Calendar Year |
Deductible, then 40% up to
$1,500 per Calendar Year |
In-patient Mental Illness &
Substance Abuse |
Deductible, then 80%;
30-day Calendar-Year Maximum |
Deductible, then 65%;
30-day Calendar-Year Maximum |
| Organ Transplant |
$250,000 Lifetime Maximum;
Subject to Large Case Management |
$250,000 Lifetime Maximum;
Subject to Large Case Mgmt |
Retail Rx - Generic Brand
(30-day supply) Brand Name |
The greater of 30% or $10 copay;
The greater of 30% or $25 copay |
N/A
N/A |
Mail-Order Rx - Generic Brand
(90-day supply) Brand Name |
$20 copay
$50 copay |
N/A
N/A |