You pay…

Annual Deductible

$100 / individual
$200 / family

Maximum Lifetime Benefit Per Person

$75,000

Service

Your Coinsurance After Annual Deductible

Medical Services in a Physician's Office

20% of Eligible Expenses

Allergy Services in a Physician's Office

20% of Eligible Expenses

Professional Fees for Surgical and Medical Services

20% of Eligible Expenses

Inpatient Hospital and Related Health Services

20% of Eligible Expenses

Outpatient Emergency Health Services

20% of Eligible Expenses

Urgent Care Center

20% of Eligible Expenses

Outpatient Surgery, Diagnostic and Therapeutic Services

20% of Eligible Expenses

Mental Health and Substance Abuse Services

• Inpatient
• Outpatient

20% of Eligible Expenses
50% of Eligible Expenses

Home Health Agency Services

20% of Eligible Expenses

Hospice Care

20% of Eligible Expenses

Ambulance Services (emergency only to nearest hospital)

20% of Eligible Expenses

Accident-related Dental Services

20% of Eligible Expenses

Prosthetic Devices and Durable Medical Equipment

20% of Eligible Expenses

Rehabilitation Services – Inpatient or Outpatient

(Includes physical therapy, occupational therapy, speech therapy, and cardiac/pulmonary rehabilitation)

20% of Eligible Expenses

Reconstructive Surgery

20% of Eligible Expenses

Health Services for the Treatment of Diabetes

20% of Eligible Expenses

Bone Mass Measurement

20% of Eligible Expenses

Service

You pay…

Retail Pharmacy
(Up to 30-day supply)

$150 deductible per calendar year
Generic: 20% (minimum $10 copayment) after deductible
Brand: 30% (minimum $10 copayment) after deductible
If actual cost is under $10, then you pay actual cost

You pay 50% of the cost (after the $150 calendar year deductible) for out-of-network claims

Mail Order – Home Delivery
(Up to 90-day supply)

Generic: $15 copayment
Brand: $35 copayment

Out-of-network claims are not covered