2008 Patient Choice Insights
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| | In-Network | Out-of-Network |
| Deductibles | None | $500 single
$1,000 family |
| Emergency Care | $50 – Waived if admitted | 80% of first $2,000, then 100% |
| Urgent Care | I. $15 office visit copay
II. $30 office visit copay
III. $50 office visit copay | 80% of first $2,000, then 100% |
| Network Hospital - General | I. 100% coverage
II. $200 admission copay
III. $200 admission copay | 70% after deductible |
| Network Hospital - Mental Health/Chemical Dependency | 100% coverage | 70% after deductible |
| In-Network Health Care Services |
| Preventive Care | 100% coverage | 70% after deductible |
| Physician | I. $15 office visit copay
II. $30 office visit copay
III. $50 office visit copay | 70% after deductible |
| Eye and Hearing Exam (nonroutine) | $15 office visit copay | 70% after deductible |
| Outpatient/surgery | I. 100% coverage
II. $75 outpatient copay
III. $75 outpatient copay | 70% after deductible |
| Outpatient Mental Health/Chemical Dependency | $15 office visit copay | 70% after deductible |
| Chiropractic Care | $15 office visit copay | 70% after deductible |
| Physical, Speech, Occupational Therapy | $15 office visit copay | 70% after deductible |
| Home Health Care | $15 home visit copay | 70% after deductible |
| Prosthetics, Durable Medical Equipment | 80% coverage, including hearing aids | 70% after deductible |
| Out-of-Network Care | | $500 deductible per person
$1,000 deductible per family
70% coinsurance of reasonable and customary charges up to annual out-of-pocket maximum |
| National Coverage | Available through emergency or out-of-network benefit only |
| Annual Out-of-Pocket Maximum |
| In-Network and Out-of-Network Total Annual | $2,500 per person
$4,000 per family |
| Lifetime Maximum | $5 million per person |
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