High Deductible Summary
This is a summary.
| 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.