Medical Deductible, Individual
|
$6,400
Combined Med/Rx
(Ded waived for Preventive Services, Primary Care OV, Other Practitioner OV, MH/SA OV, Generic Drugs, Preventive Drugs, Family Planning, Pediatric Vision, and Hospice.)
|
N/A
|
$525 (Applies to OP Facility and IP services only)
|
$2500 (Applies to OP Facility and IP services only)
|
$4950(Applies to OP Facility and IP services only)
|
$3800 (Applies to OP Facility and IP services only)
|
$6,650 Combined Med/Rx (Ded waived for all Primary Care and Other Prac OV, Specialist OV, Dialysis, Urgent Care, Preventive Services, MH/SA OV, Generic Drugs, Preventive Drugs, Family Planning, Pediatric Vision, and Hospice.)
|
$250 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab,
Inpatient, DME, Ambulance)
|
$700 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab,
Inpatient, DME, Ambulance)
|
$3000 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab,
Inpatient, DME, Ambulance)
|
$3500 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab,
Inpatient, DME, Ambulance)
|
Medical Deductible, Family
|
$12,800
Combined Med/Rx
(Ded waived for Preventive Services, Primary Care OV, Other Practitioner OV, MH/SA OV, Generic Drugs, Preventive Drugs, Family Planning, Pediatric Vision, and Hospice.)
|
N/A
|
$1050 (Applies to OP Facility and IP services only)
|
$5000 (Applies to OP Facility and IP services only)
|
$9,900
(Applies to OP Facility and IP services only)
|
$7600 (Applies to OP Facility and IP services only)
|
$13,300 Combined Med/Rx
(Ded waived for all Primary Care and Other Prac OV, Specialist OV, Dialysis, Urgent Care, Preventive Services, MH/SA OV, Generic Drugs, Preventive Drugs, Family Planning, Pediatric Vision, and Hospice.)
|
$500 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab,
Inpatient, DME, Ambulance)
|
$1400 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab,
Inpatient, DME, Ambulance)
|
$6000 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab,
Inpatient, DME, Ambulance)
|
$7000 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab,
Inpatient, DME, Ambulance)
|
Rx Deductible, Individual
|
Included in Medical deductible
|
N/A
|
N/A
|
$400 (Ded applies to Tiers 3 and 4)
|
$400 (Ded applies to Tiers 3 and 4)
|
N/A
|
Included in Medical deductible
|
N/A
|
N/A
|
$200 (Ded applies to Tier-4)
|
$500 (Ded applies to Tier-4)
|
Rx Deductible, Family
|
Included in Medical deductible
|
N/A
|
N/A
|
$800 (Ded applies to Tiers 3 and 4)
|
$800 (Ded applies to Tiers 3 and 4)
|
N/A
|
Included in Medical deductible
|
N/A
|
N/A
|
$400 (Ded applies to Tier-4)
|
$1000 (Ded applies to Tier-4)
|
OOPM, Individual
|
$7,350
|
$1,250
|
$2,450
|
$5,850
|
$7,350
|
$7,350
|
$7,350
|
$1,250
|
$2,450
|
$5,850
|
$7,350
|
OOPM, Family
|
$14,700
|
$2,500
|
$4,900
|
$11,700
|
$14,700
|
$14,700
|
$14,700
|
$2,500
|
$4,900
|
$11,700
|
$14,700
|