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Deductible options
Annual amount you pay before benefits are paid
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$500, $1,000 and $2,500 for individual.
Family deductible is three times the individual deductible (family = 3
or more people).
Individual non-network deductible is plan deductible + $1,000.
Family non-network deductible is three times the individual non-network
deductible.
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Coinsurance options |
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50% or 75%
Non-network coinsurance is network coinsurance less 20%.
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Coinsurance out-of-pocket maximum
Total out-of-pocket maximum equals coinsurance maximum plus deductible
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$2,000 when you choose 50% coinsurance.
$3,000 when you choose 75% coinsurance.
Individual non-network out-of-pocket maximum is $8,000 for both coinsurance options.
Family non-network out-of-pocket maximum is $16,000 for both coinsurance options.
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Doctor Office Copay (DOC)
Optional benefit
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$25 per
visit up to 2 visits per person each calendar year.
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Annual Maximum
$50,000 and $250,000 options also available
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$100,000 per year |
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Outpatient services maximum
$5,000 and $10,000 options also available |
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$2,500
per year (Available with $50,000 and $100,000 annual maximums) (Additional options available with $100,000 and $250,000 annual maximums)
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Prescription drugs maximum
Annual maximum amount available as buy-up option
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$2,000 limit per person each year
Generic: $15 copay / No deductible
Brand: $25 copay + 50% coinsurance / $500 deductible.
(If you choose brand when generic is available, you will pay the difference.)
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Lifetime maximum |
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$2 million
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Accident Medical Expense (AME)
Optional benefit |
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$300, $500 or $1,000
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This plan information contains a general summary of benefits. Please refer to the certificate of coverage for actual terms and conditions.
