High Deductible Summary

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Plan Summary Effective 2017-18
Service In-Network Benefits
Member Pays
Out-of-Network Benefits
Member Pays
Calendar Year Deductible* $2,000 single
$4,000 family
$5,000 individual†
$10,000 Family†
Medical Out-of-Pocket Maximum
(deductibles and coinsurance)
$3,000 single
$6,000 family
$6,350 individual†
$12,700 family†
Preventive Care
(wellness exams, cancer screenings, immunizations)
0% 50% after deductible†
Office Visits
(primary care physician)
20% after deductible
0% after out-of-pocket
50% after deductible†
Behavioral Health 20% after deductible
0% after out-of-pocket
50% after deductible†
Specialist/Allergist 20% after deductible
0% after out-of-pocket
50% after deductible†
Physician Services
(outside of office)
20% after deductible
0% after out-of-pocket
50% after deductible†
Diagnostic X-Rays and Lab Work 10% or 20% after deductible**
0% after out-of-pocket
50% after deductible†
Free-Standing Laboratory 20% after deductible**
0% after out-of-pocket
50% after deductible†
Advanced Imaging 
(such as MRI, CAT, PET)
10% or 20% after deductible**
0% after out-of-pocket
50% after deductible†
Free-Standing Advanced Imaging 20% after deductible
0% after out-of-pocket
50% after deductible†
Hospital Emergency Room Services 10% or 20% after deductible**
0% after out-of-pocket
50% after deductible†
Urgent Care Facility 10% or 20% after deductible**
0% after out-of-pocket
50% after deductible†
Speech Therapy
(limit 30 visits per year)
20% after deductible
0% after out-of-pocket
50% after deductible†
Physical and Occupational Therapy
(limit 60 visits per year)
20% after deductible
0% after out-of-pocket
50% after deductible†
Acupuncture
(limit 20 visits per year)
20% after deductible
0% after out-of-pocket
50% after deductible†
Chiropractic Services
(limit 20 visits per year)
20% after deductible
0% after out-of-pocket
50% after deductible†
Pharmacy 20% after deductible
0% after out-of-pocket
50% after deductible†

* For other than single coverage, the family deductible and out-of-pocket maximum applies.

** Coinsurance percentage based on network Hospital Tiering

† Out-of-network providers may balance bill you for charges in excess of the maximum allowable fee. You will be responsible for charges in excess of the maximum allowable fee in addition to any applicable deductible, coinsurance or co-payment. Additionally, any amount you pay the provider in excess of the maximum allowable fee will not apply to your deductible.