Cost Sharing Benefits (In Network)
Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.
Deductible (Individual) |
$6,150 |
Deductible (Family) |
$12,300 |
Coinsurance |
Not applicable |
Out of Pocket Maximum (Individual) |
$6,500 |
Out of Pocket Maximum (Family) |
$13,000 |
Doctor Visits
Primary Care Visit |
Data Not Available |
Specialist Visit |
$50 Copay after deductible |
Inpatient Facility |
$750 Copay per stay |
Inpatient Physician |
No charge |
Emergency Room Services |
$350 Copay after deductible |
Tests and Imaging
Imaging (CT/PET Scans, MRIs) |
75% Coinsurance after deductible |
Laboratory Outpatient and Professional Services |
100% Coinsurance after deductible |
X-Ray and Diagnostic Imaging |
100% Coinsurance after deductible |
Health Management Programs
Asthma |
Available |
Depression |
Available |
Diabetes |
Available |
Heart Disease |
Not available |
High Blood Pressure / High Cholesterol |
Not available |
Lower Back Pain |
Not available |
Pain Management |
Not available |
Pregnancy |
Not available |
Weight Loss |
Not available |
Other
Mental / Behavioral Health Inpatient |
$750 Copay per stay |
Mental / Behavioral Health Outpatient |
Data Not Available |
Rehabilitative Speech Therapy |
$50 Copay after deductible |
Rehabilitative Occupational & Physical Therapy |
$50 Copay after deductible |
Outpatient Facility |
50% Coinsurance after deductible |
Outpatient Surgery |
50% Coinsurance after deductible |
Prescription Drugs
Generic Rx |
Data Not Available |
Preferred Brand Rx |
Data Not Available |
Non Preferred Brand Rx |
$60 Copay after deductible |
Specialty Drugs
| 30% Coinsurance after deductible |