COVERED MEDICAL SERVICES
|
Physician Services (paid offer deductible) |
Physician Services |
Physician Services |
|
Office visits |
80% |
50% |
|
Preventive Care Services
(paid after deductible) |
Preventive Care Services |
Preventive Care Services |
|
Physical exams |
80% |
50% |
|
General wellness |
80% |
50% |
|
Well child care |
80% |
50% |
|
Other Physician Services
(paid after deductible) |
Other Physician Services |
Other Physician Services |
|
Surgical procedures, assistant surgeon, and
anesthesia |
80% |
50% |
|
Hospital visits |
80% |
50% |
|
Maternity Benefits (if included
in plan) |
Maternity Benefits |
Maternity Benefits |
|
Prenatal and postnatal
care |
80% after deductible |
50% after deductible |
|
Delivery and facility
charges |
80% after deductible |
50% after deductible |
|
Hospital Services (paid
after deductible) |
Hospital Services |
Hospital Services |
|
Inpatient |
80% |
50% |
|
Outpatient surgical
facility |
80% |
50% |
|
Other outpatient charges |
80% |
50% |
|
Emergency room |
80% |
50% |
|
Newborn nursery and
inpatient pediatric care |
80% |
50% |
|
Other Services (paid
after deductible) |
Other Services |
Other Services |
|
Prescription drug
benefits See plan highlights |
80% |
50% |
|
Hospice care |
80% |
50% |
|
Home health care |
80% |
50% |
|
Extended care facility |
80% |
50% |
|
Medical equipment and
supplies |
80% |
50% |
|
Outpatient X-ray, lab
tests, diagnostic imaging and radiation therapy |
80% |
50% |
|
Outpatient therapies
(habilitative, rehabilitative, and treatments) |
80% |
50% |
|
Mental Health/Substance Abuse (if included in plan) |
Mental Health/Substance Abuse |
Mental Health/Substance Abuse |
|
Inpatient |
80% after deductible |
50% after deductible |
|
Outpatient |
50% after deductible |
50% after deductible |
|
Deductible
(calendar year) |
$100, $200, $500, $1000,
$1500, $2250 or $5000 |
$100, $200, $500, $1000,
$1500, $2250 or $5000 |
|
Out-of-Pocket
limit (excluding deductible) |
$500, $1000, $2000 |
$500, $1000, $2000 |