|
Primary Care Office Visit
|
A: Adult: $15
Child: $45
F: Adult: $25
Child: $0
|
Deductible, then $30 |
Deductible, then $30 |
| Specialist Office Visit |
$45 |
Deductible, then $50
(riders available on non-HSA qualified)
|
Deductible, then $50
(riders available on non-HSA qualified)
|
Inpatient
(per admission)
|
A: $250 - $750
F: Adult: $750
Child: $0
|
Deductible, then coinsurance |
Deductible, then coinsurance
capped at $1,000 per event
|
| Outpatient Surgery |
$200 |
Deductible, then coinsurance |
Deductible, then coinsurance
|
Out-of-Pocket Maximum
(In-Network)
|
N/A |
E: $4,000/$8,000
S: $6,000/$12,000
(other options available)
|
$5,000/$10,000
(other options available)
|
Deductible
(In-Network)
|
N/A |
E: $1,500/$3,000
S: $2,500/$5,000
(other options available)
|
$1,500/$3,000
combined in and out of network
(other options available)
|
Coinsurance
(In-Network)
|
N/A |
E: 20%
S: 30%
|
20% |
| Wellness |
$250 benefit card to use for approved health and wellness expenses. |
Out-of-pocket incentives for those who make the effort to lead healthier lifestyles. |
FitWorksSM Reward Program (an Amazon.com Gift Card* claim code valued at $250 per subscriber and up to $250 per covered spouse) for participating in health and wellness challenges, completing preventive screenings, etc.
|