2009 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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