You’re covered wherever you go in our nationwide network.
| Benefit/Service | Network / Non-network |
|---|---|
| Deductible | |
| Employee | $600 / N/A |
| Employee + 1 | $900 / N/A |
| Employee + Children | $900 / N/A |
| Family | $1200 / N/A |
| Out-of-pocket maximum | |
| Employee | $2000 / N/A |
| Employee + 1 | $3000 / N/A |
| Employee + Children | $3000 / N/A |
| Family | $4000 / N/A |
| Annual HRA Contribution | |
| Employee | N/A |
| Employee + 1 | N/A |
| Employee + Children | N/A |
| Family | N/A |
| Lifetime maximum benefit | $2 million |
| Office / Doctor visit | $35 copay; 100% |
| Specialist visit | $35 copay; 100% |
| Urgent care visit | $35 copay; 100% |
| Emergency room | $150 copay / 100% |
| Ambulance | 100% / 100% |
| Outpatient surgery | 80%; subj to ded |
| Hospital stay | 80%; subj to ded |
| Maternity Care/Office Visit | 80%; subj to ded |
| Well-child visits | $35 copay; 100% |
| Mammogram | 100% |
| Annual adult physical | $35 copay; 100% |