MEDICAL PLAN SUMMARY
Same plan design in or out-of-network. However network providers can save you money. Network providers offer 20-40% price discounts and file your claims for you.
| Annual Maximum (in or out-of-network) |
$5,000
|
| Annual Deductible - Individual / Family |
$200 / $500
|
| Outpatient Medical Expense Benefit |
$2,000
|
| Doctors' Office Visits (Lab and X-ray on same bill) |
|
| Per visit co-pay 1. |
$15
|
| Co-insurance |
100%
|
| Diagnostic, Surgical, & Emergency Room Visit 1.2. |
80%
|
| Prescription Coverage Benefit 1.2.3. |
80%
|
| Inpatient Medical Expense Benefit |
|
| Co-insurance |
80%
|
Inpatient Physician Services
(surgeon, anesthesiologist, doctor visits in hospital, etc.) |
80% |
| Other Hospital Services Annual Maximum |
$1,000
|
| Daily Room & Board Maximum |
$200
|
| Daily ICU Room & Board Maximum |
$400
|
| Accidental Death and Dismemberment |
|
| Included in the Medical Benefit (Not available in some states.) |
|
| Employee |
$10,000
|
| Spouse |
$5,000
|
| Child |
$2,500
|
| Optional Prescription Drug Co-pay Card |
|
| Per Month Maximum (no carryover) |
$50
|
| Generic / Branded Co-pay |
$10 / $30
|
| |
1. Subject to Outpatient Maximum
2. After Plan Deductible
3. Reimburstment Method
|
|
