|
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) Individual
|
$8,500
|
$8,700
|
|
|
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) Family
|
$8500 per person | $17000 per group
|
$8700 per person | $17400 per group
|
per person not applicable | per group not applicable
|
|
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) Combined In/Out Network Family
|
per person not applicable | per group not applicable
|
|
|
|
Medical EHB Deductible Individual
|
$3,500
|
$3,500
|
|
|
Medical EHB Deductible Family
|
$3500 per person | $7000 per group
|
$3500 per person | $7000 per group
|
per person not applicable | per group not applicable
|
|
Medical EHB Deductible Default Coinsurance
|
40.00%
|
50.00%
|
|
|
Medical EHB Deductible Combined In/Out Network Family
|
per person not applicable | per group not applicable
|
|
|
|
Drug EHB Deductible Default Coinsurance
|
30.00%
|
30.00%
|
|
|
Drug EHB Deductible Combined In/Out Network Family
|
per person not applicable | per group not applicable
|
|
|
|
HSA/HRA Detail Combined In/Out Network HSA Eligible*
|
No
|
|
|
|
Primary Care Visit to Treat an Injury or Illness
|
$35.00
|
$80.00
|
100.00%
|
|
Specialist Visit
|
$60.00
|
50.00% Coinsurance after deductible
|
100.00%
|
|
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
40.00% Coinsurance after deductible
|
50.00% Coinsurance after deductible
|
100.00%
|
|
Outpatient Surgery Physician/Surgical Services
|
40.00% Coinsurance after deductible
|
50.00% Coinsurance after deductible
|
100.00%
|
|
Urgent Care Centers or Facilities
|
$0.00
|
$80.00
|
100.00%
|
|
Emergency Room Services
|
40.00% Coinsurance after deductible
|
40.00% Coinsurance after deductible
|
40.00% Coinsurance after deductible
|
|
Emergency Transportation/Ambulance
|
40.00% Coinsurance after deductible
|
40.00% Coinsurance after deductible
|
40.00% Coinsurance after deductible
|
|
Inpatient Hospital Services (e.g., Hospital Stay)
|
40.00% Coinsurance after deductible
|
50.00% Coinsurance after deductible
|
100.00%
|
|
Mental/Behavioral Health Outpatient Services
|
$35.00
|
$80.00
|
100.00%
|
|
Mental/Behavioral Health Inpatient Services
|
40.00% Coinsurance after deductible
|
50.00% Coinsurance after deductible
|
100.00%
|
|
Generic Drugs
|
$15.00
|
$15.00
|
100.00%
|
|
Preferred Brand Drugs
|
$50.00
|
$50.00
|
100.00%
|
|
Non-Preferred Brand Drugs
|
$125.00
|
$125.00
|
100.00%
|
|
Specialty Drugs
|
30.00%
|
30.00%
|
100.00%
|
|
Preventive Care/Screening/Immunization
|
No Charge
|
No Charge
|
100.00%
|
|
Dental Check-Up for Children
|
No Charge
|
No Charge
|
100.00%
|
|
Basic Dental Care – Child
|
No Charge
|
No Charge
|
100.00%
|
|
Orthodontia – Child
|
50.00%
|
50.00%
|
100.00%
|