|
Plan 1 |
Plan 2 |
Plan 3 |
||||
|
In Network |
Out of Network |
In Network |
Out of Network |
In Network |
Out of Network |
|
|
Lifetime Maximum
|
$2,000,000 |
$2,000,000 |
$2,000,000 |
$2,000,000 |
$2,000,000 |
$2,000,000 |
|
Deductible
|
$1,000 member/$3,000 Family. Deductible applies to all services |
Not Covered |
$3,000 member/$9,000 Family Deductible applies to all services |
Not Covered |
$3,000 member/$9,000 Family Deductible applies to all services |
Not Covered |
|
Coinsurance
|
Group Health Pays 80%/Member pays 20% |
Not Covered |
Group Health Pays 70%/Member pays 30% |
Not Covered |
Group Health Pays 70%/Member pays 30% |
Not Covered |
|
Out of Pocket
|
$5,000 member/$15,000 family |
Not Covered |
$5,000 member/$15,000 family |
Not Covered |
$5,000 member/$15,000 family |
Not Covered |
|
Outpatient Physician Visits
|
$20 copay + Coinsurance |
Not Covered |
$25 copay + Coinsurance |
Not Covered |
$25 copay + Coinsurance |
Not Covered |
|
Hospital
|
||||||
|
Inpatient
|
Deductible/ |
Emergency Only |
Deductible/ |
Emergency Only |
Deductible/ |
Emergency Only |
|
Outpatient Surgery
|
$20 copay + Deductible/ |
Emergency Only |
$25 copay + Deductible/ |
Emergency Only |
$25 copay + Deductible/ |
Emergency Only |
|
Emergency
|
$150 copay + Coinsurance after annual deductible |
$200 copay + Coinsurance after annual deductible |
$150 copay + Coinsurance after annual deductible |
$200 copay + Coinsurance after annual deductible |
$150 copay + Coinsurance after annual deductible |
$200 copay + Coinsurance after annual deductible |
|
(copay waived if admitted) |
Not Covered |
(copay waived if admitted) |
Not Covered |
(copay waived if admitted) |
Not Covered |
|
|
Preventive Care
|
$20 copay + Coinsurance |
$20 copay + Coinsurance |
$25 copay + Coinsurance |
$25 copay + Coinsurance |
$25 copay + Coinsurance |
$25 copay + Coinsurance |
|
Diagnostic
|
||||||
|
Lab & Xray
(Outpatient) |
Deductible/ |
Not Covered |
Deductible/ |
Not Covered |
Deductible/ |
Not Covered |
|
Mental Health
|
||||||
|
Inpatient
|
Deductible/Coinsurance |
Not Covered |
Deductible/Coinsurance |
Not Covered |
Deductible/Coinsurance |
Not Covered |
|
Outpatient
|
$20 copay, deductible and coinsurance apply
|
Not Covered |
$25 copay, deductible and coinsurance apply
|
Not Covered
|
$25 copay, deductible and coinsurance apply
|
Not Covered
|
|
|
|
|
||||
|
Prescriptions
|
|
|
|
|
|
|
|
(Retail - 30 Day Supply)
|
$20 Generic /
Greater of $40 or 50% Brand
|
Not Covered
|
$20 Generic / Greater of $40 or 50% Brand |
Not Covered |
Not Covered
|
Not Covered
|
|
(Mail - 90 Day Supply)
|
2 x prescription cost share per 90 day supply
|
Not Covered
|
2 x prescription cost share per 90 day supply
|
Not Covered
|
Not Covered
|
Not Covered
|
|
|
|
|
|
|
|
|
|
Welcome
Plan Feature |
Not Applicable
|
Not Applicable
|
Not Applicable
|
Not Applicable
|
Not Applicable
|
Not Applicable
|
|
Physical Therapy
|
|
|
|
|||
|
(Inpatient)
|
Coinsurance, 60 days PCY
|
Not Covered
|
Coinsurance, 60 days PCY
|
Not Covered
|
Coinsurance, 60 days PCY
|
Not Covered
|
|
(Outpatient)
|
$20 copay+ Coinsurance
|
Not Covered
|
$25 + Coinsurance
|
Not Covered
|
$25 + Coinsurance
|
Not Covered
|
|
60 Visits PCY
|
|
60 Visits PCY
|
|
60 Visits PCY
|
|
|
|
Spinal Manipulations
|
$20 copay+ Coinsurance
|
Not Covered
|
$25 copay + Coinsurance
|
Not Covered
|
$25 copay + Coinsurance
|
Not Covered
|
|
10 Visits PCY
|
|
10 visits PCY
|
|
10 visits PCY
|
|
|
|
Acupuncture
|
$20 copay + Coinsurance
|
Not Covered
|
$25 copay + Coinsurance
|
Not Covered
|
$25 copay + Coinsurance
|
Not Covered
|
|
8 Visits PCY
|
|
8 visits PCY
|
|
8 visits PCY
|
|
|
|
Vision Exam
|
$20 copay
|
Not Covered
|
$25 Copay
|
Not Covered
|
$25 Copay
|
Not Covered
|
|
1 exam every 12 mos
|
|
1 exam every 12 mos
|
|
1 exam every 12 mos
|
|
|
|
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Medical Plans Overview: Option Health Care Plans
|
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Plan Comparison: (Information as of 4/1/10) Your Quick Guide to Compare the Group Health Plans
|
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