|
Consumer Choice 1 |
Consumer Choice 2
|
Pre-Existing Condition Exclusion | None | None |
Out-of-Pocket Expenses |
In-Network |
Out-of-Network |
In-Network |
Out-of-Network |
Deductible |
Employee only: $1,600
Family: $3,200 |
Employee only: $3,550
Family: $7,100
|
Annual Out-of-Pocket Maximum
(Includes deductible) |
Employee only
$3,200
Family
$6,400 |
Employee only
$6,400
Family
$12,800 |
Employee only
$3,550
Family
$7,100 |
Employee only
$7,100
Family
$ 14,200 |
Benefits |
In-Network |
Out-of-Network |
In-Network |
Out-of-Network |
Coinsurance Paid After Deductible
(Applies to all professional services except those noted below.) | You Pay 20% | You Pay 40% | Plan Pays 100% | You Pay 40% |
Office Visit Copays
(Copays do not apply to deductible or out-of-pocket maximum) | Subject to Deductible and Coinsurance | Subject to Deductible
and Coinsurance |
Lab Work/ Professional Services | Subject to Deductible
and Coinsurance | Subject to Deductible
and Coinsurance, then
Plan Pays 100% |
Emergency Room Visit Copayment | Subject to Deductible
and Coinsurance | Subject to Deductible
and Coinsurance, then
Plan Pays 100% |
Wellness Benefit | 100% of In-Network
Eligible Charges | 100% of In-Network
Eligible Charges |
Benefit Limits |
Maximum Lifetime Benefit
(Unless noted) | Unlimited | Unlimited |
Substance Abuse Treatment | Subject to Deductible
and Coinsurance | Subject to Deductible
and Coinsurance |
Mental Illness | Subject to Deductible
and Coinsurance | Subject to Deductible
and Coinsurance |
Chiropractic | Subject to Deductible
and Coinsurance | Subject to Deductible
and Coinsurance |
Hearing Aids |
Up to $1,500 After the Deductible is Met Every 3 Years Per Person Covered |
Up to $1,500 After the Deductible is Met Every 3 Years Per Person Covered |
Temporomandibular Joint Dysfunction and Related Disorders | Subject to Deductible
and Coinsurance | Subject to Deductible
and Coinsurance |
Physical, Occupational
and Speech Therapy | Subject to Deductible
and Coinsurance | Subject to Deductible
and Coinsurance |
