Limitation

In-Network

Out-Of-Network

Coinsurance

30%

40%

Copayment

$20

None

Deductible Levels

$2250/4500

Coinsurance Maximum

$1000/2000

Dependent/Student Age

19/23

Hospital/Facility Benefits

Hospital/Facility Inpatient

Unlimited Days Semi-Private Room & Board

Ded/30% Coins*

Ded/40% Coins*

Maternity Care

Ded/30% Coins*

Ded/40% Coins*

Routine Newborn Nursery Care

30% Coinsurance

Ded/40% Coins

Hospital/Facility Outpatient

Ambulatory Surgery

Ded/30% Coins

Ded/40% Coins

Pre-Admission Testing

Ded/30% Coins

Ded/40% Coins

Kidney Dialysis

Ded/30% Coins

Ded/40% Coins

Professional & Additional Benefits

Physician

Office Visit/Consultation

$20 Copay

Ded/40% Coins

Chiropractic Services

$20 Copay

Ded/40% Coins

Routine Pap Smear

Covered In Full

Ded/40% Coins

Routine Mammography Screening

Covered In Full

Ded/40% Coins

Allergy Testing

$20 Copay

Ded/40% Coins

Allergy Injections

Covered In Full

Ded/40% Coins

Second Surgical Opinion/Second Medical Opinion

$20 Copay

Ded/40% Coins

Pre/Post Natal Care

Ded/30% Coins

Ded/40% Coins

In-Hospital/In-Facility Physician Services/Consultation

Ded/30% Coins

Ded/40% Coins

Anesthesia

Ded/30% Coins

Ded/40% Coins

Gynecological Visits

$20 Copay

Ded/40% Coins

Preventive

Annual Routine Physical

1 per year

$20 Copay

Not Covered

Well Child Care Visits/Immunizations up to age 19

Covered In Full

Covered In Full

Routine Gynecological Exam

1 per year

Covered In Full

Ded/40% Coins

Alcohol/Substance Abuse Inpatient/Outpatient

Inpatient Detoxification

7 days

Ded/30% Coins*

Ded/40% Coins*

Outpatient Alcohol/Substance Abuse

60 visits/20 family

Ded/30% Coins

Ded/40% Coins

Mental Health Inpatient/Outpatient

Inpatient Mental Health

30 days

Ded/30% Coins*

Ded/40% Coins*

Outpatient Mental Health

30 visits per year

$20 Copay

Ded/40% Coins

General Services

Diagnostic Machine Tests

Ded/30% Coins

Ded/40% Coins

Diagnostic X-Ray

Ded/30% Coins

Ded/40% Coins

Diagnostic Laboratory

Ded/30% Coins

Ded/40% Coins

Chemotherapy/Radiation

Ded/30% Coins

Ded/40% Coins

Ambulance (ground)

Ded/30% Coins

Ded/40% Coins

Ambulance (air)

Ded/30% Coins

Ded/40% Coins

Diabetes Education, Equipment, & Supplies

supplies-30 day supply

$20 Copay

Ded/40% Coins

Hospice

210 days

30% Coinsurance

Ded/40% Coins

Home Health Care

40 visits

Ded/30% Coins*

Ded/40% Coins*

DME, Prosthetics/Medical Supplies

Ded/30% Coins*

Ded/40% Coins*

Short Term Therapies To Include: Speech, Occupational, Respiratory, Physical, Cardiac

$20 Copay

Ded/40% Coins

Skilled Nursing Facility

45, 60, 120 days

Ded/30% Coins*

Ded/40% Coins*

Private Duty Nursing

Ded/30% Coins

Ded/40% Coins

MRI/MRA

Ded/30% Coins

Ded/40% Coins

Infusion Therapy

Ded/30% Coins*

Ded/40% Coins*

Anesthesia

Ded/30% Coins

Ded/40% Coins

Emergency Services

Medical Emergency/Urgent Care

$50 Copay per visit

Ded/40% Coins

Accidental Injury

$50 Copay per visit

Ded/40% Coins