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 |
