In-Network

Out-of-Network*

Annual Deductible Amount for injury, illness, or maternity

None

$200 / individual
$400 / family

Out-of-Pocket Annual Limit (excludes deductible)

$1,000 / individual
$2,000 / family

$3,000 / individual
$6,000 / family

Pre-Existing Conditions

n/a

n/a

Maximum Lifetime Benefit

Unlimited

$2,000,000

Annual Reinstatement

n/a

n/a

Services Covered

In-Network

Out-of-Network*

Laboratory and X-ray

Covered 100%

Covered 80% of R&C*
after deductible

Home Health Care
(skilled visits only) – 60 days per calendar year, in-network and out-of-network combined

Maximum number of hours per day is limited to 16 hours. Multiple visits can occur in one day; with a visit defined as a period of 2 hours or less.

Covered 100%

Covered 80% of R&C*
after deductible

Durable Medical Equipment

Covered 100%; maximum of $3,500 per calendar year

Not covered

External Prosthetic Devices –
Requires approval by Health Plan

Covered 100% after $200
deductible; maximum of $1,000 per calendar year

Not covered

Hospital Care

Services Covered

In-Network

Out-of-Network*

Inpatient Services:
Operating room, X-ray, and laboratory services.
Includes stand-alone facilities such as Birthing Center

Covered 100%,
no copayment

Covered 80% of
R&C* after deductible

Outpatient Services:

• Outpatient surgery

Covered 100%

Covered 80% of
R&C* after deductible

• Physician’s Office

Transplant Coverage:

• Inpatient Facility

Covered 100% at approved facilities

Not covered

• Travel Benefit

Emergency Room Services (not covered if not true Emergency)

Covered 100% after $50
copayment (waived if admitted)

Covered 100% after $50 copayment (waived if admitted)

Ambulance Services (not covered if not true Emergency)

Covered 100%

Covered 100%

Urgent Care Facility (not covered if not true Emergency)

Covered 100% after $25 copayment

Covered 100% after $25 copayment

Inpatient Mental Health –
20 days per calendar year in-network and out-of-network combined

Covered 100%

Covered 80% of R&C*
after deductible

Inpatient Substance Abuse –
20 days per calendar year in-network and out-of-network combined

Covered 100%

Covered 80% of R&C*
after deductible

Physician Care

Services Covered

In-Network

Out-of-Network*

Maternity – Inpatient

Covered 100%

Covered 80% of R&C*
after deductible

Skilled Nursing Facility
60 days per calendar year for in-network and out-of-network combined

Covered 100%

Covered 80% of R&C*
after deductible

Hospice Care (inpatient and outpatient)

Covered 100%, no copayment

Covered 80% of R&C*
after deductible

Outpatient (short-term) Rehabilitation – 20 visits in-network and out-of-network combined. Includes physical, speech, cardiac and occupational therapy

Covered 100% after $10 copayment per visit

Covered 80% of R&C*
after deductible

Primary Care or
Specialist Office Visit

Covered 100% after $10 copayment

Covered 80% of R&C*
after deductible

Vision Exam Services
Provided by VSP

Annual Vision Exam – covered 100% after $10 copayment

Eyewear Allowance: $150 allowance every 12 months for children up through age 17; every 24 months for age 18 and over

Not covered

Physician and Surgeon
Services in Hospital

Covered 100%

Covered 80% of R&C*
after deductible

Maternity Office Visits

Covered 100% after one-time $10
office visit copayment

Covered 80% of R&C
after deductible

Maternity Delivery
(Physician charges)

Covered 100%

Covered 80% of R&C*
after deductible

Preventive Health Services:

• Well-Baby Care

Covered 100% after $10 copayment (including immunizations)

Not covered

• Periodic Health Assessments

Covered 100% after $10 copayment

Not covered

• Routine Gynecological Exams

Covered 100% after $10 copayment

Not covered

• Routine Mammogram

No charge (no referral needed)

Covered 80% of R&C*
after deductible

• Hearing Aid Benefits

Not covered

Not covered

Chiropractic Care (when medically appropriate) –
25 visit limit per year

Covered 100% after $10 copayment per visit

Not covered

Substance Abuse:

• Outpatient – 35 visit limit per calendar year in-network and out-of-network combined

Covered 100% after $10 copayment per visit for individual therapy;
Covered 100% after $10 copayment per visit for group therapy

Covered 80% of R&C* after deductible

Mental Health Service:

• Outpatient – 35 visit limit per calendar year in-network and out-of-network combined

Covered 100% after $10 copayment per visit

Covered 80% of R&C* after deductible

Physician Services in Emergency Room

Covered 100%

Covered 100%

Infertility Treatment:

• Physician office visit, test, counseling
• Surgical Treatment – includes procedures for correction of infertility (invitro fertilization, artificial insemination, GIFT, ZIFT, etc.)

Not covered

Not covered

Prescription Drugs, administered by Medco

Services Covered

In-Network

Out-of-Network*

Retail Pharmacy
(Up to a 30-day supply)

Generic: 100% after $5 copayment
Brand: 100% after $15 copayment
Select: 100% after $35 copayment

Covered 80% after deductible

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

Generic: 100% after $5 copayment per 30-day supply
Brand: 100% after $15 copayment per 30-day supply
Select: 100% after $35 copayment per 30-day supply

Not covered