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Highlights:
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Deductible
options
Annual amount you pay before
benefits are paid |
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$500,
$1,000 and $2,500 for individual.
Family
deductible is three times the individual deductible
(family = 3 or more people).
Individual
non-network deductible is plan deductible + $1,000.
Family
non-network deductible is three times the individual
non-network deductible.
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Coinsurance
options |
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50%
or 75%
Non-network
coinsurance is network coinsurance less 20%. |
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Coinsurance
out-of-pocket maximum
Total out-of-pocket maximum
equals coinsurance maximum plus deductible |
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$2,000
when you choose 50% coinsurance.
$3,000 when you choose 75% coinsurance.
Individual
non-network out-of-pocket maximum is $8,000 for both
coinsurance options.
Family
non-network out-of-pocket maximum is $16,000 for both
coinsurance options.
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Doctor
Office Copay (DOC)
Optional benefit |
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$25
per visit up to 2 visits per person each calendar year. |
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Annual
Maximum
$50,000 and $250,000 options
also available |
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$100,000
per year |
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Outpatient
services maximum
$5,000 and $10,000 options
also available |
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$2,500
per year (Available with $50,000 and $100,000 annual
maximums) (Additional options available with $100,000
and $250,000 annual maximums) |
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Prescription
drugs maximum
Annual maximum amount
available as buy-up option |
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$2,000
limit per person each year
Generic:
$15 copay / No deductible
Brand:
$25 copay + 50% coinsurance / $500 deductible.
(If you choose brand when generic is available, you will
pay the difference.) |
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Lifetime
maximum |
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$2
million |
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Accident
Medical Expense (AME)
Optional benefit |
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$300,
$500 or $1,000 |
Note:
All maximums are on a calendar-year basis. Options may vary by
state.
Non-network out-of-pocket maximums do not apply to Traditional
plans. Subject to reasonable and customary charges.
Doctor Office Copay option not available with Traditional plans.
Family deductible is 2 times.
This plan
information contains a general summary of benefits. Please refer
to the certificate of coverage for actual terms and conditions.
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