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) |
$1,000 |
| Deductible (Family) |
$2,000 |
| Coinsurance |
Not applicable |
| Out of Pocket Maximum (Individual) |
$5,000 |
| Out of Pocket Maximum (Family) |
$10,000 |
Doctor Visits
| Primary Care Visit |
Data Not Available |
| Specialist Visit |
Data Not Available |
| Inpatient Facility |
20% Coinsurance after deductible |
| Inpatient Physician |
No charge |
| Emergency Room Services |
20% Coinsurance after deductible |
Tests and Imaging
| Imaging (CT/PET Scans, MRIs) |
Data Not Available |
| Laboratory Outpatient and Professional Services |
Data Not Available |
| X-Ray and Diagnostic Imaging |
Data Not Available |
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 |
20% Coinsurance after deductible |
| Mental / Behavioral Health Outpatient |
Data Not Available |
| Rehabilitative Speech Therapy |
Data Not Available |
| Rehabilitative Occupational & Physical Therapy |
Data Not Available |
| Outpatient Facility |
$150 Copay after deductible |
| Outpatient Surgery |
$150 Copay after deductible |
Prescription Drugs
| Generic Rx |
Data Not Available |
| Preferred Brand Rx |
$40 Copay after deductible |
| Non Preferred Brand Rx |
$80 Copay after deductible |
| Specialty Drugs
| 30% Coinsurance after deductible |
