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) |
$0 |
Deductible (Family) |
$0 |
Coinsurance |
Not applicable |
Out of Pocket Maximum (Individual) |
$7,350 |
Out of Pocket Maximum (Family) |
$14,700 |
Doctor Visits
Primary Care Visit |
Data Not Available |
Specialist Visit |
Data Not Available |
Inpatient Facility |
Data Not Available |
Inpatient Physician |
Data Not Available |
Emergency Room Services |
Data Not Available |
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 |
Not available |
Diabetes |
Available |
Heart Disease |
Available |
High Blood Pressure / High Cholesterol |
Available |
Lower Back Pain |
Not available |
Pain Management |
Not available |
Pregnancy |
Available |
Weight Loss |
Available |
Other
Mental / Behavioral Health Inpatient |
Data Not Available |
Mental / Behavioral Health Outpatient |
Data Not Available |
Rehabilitative Speech Therapy |
Data Not Available |
Rehabilitative Occupational & Physical Therapy |
Data Not Available |
Outpatient Facility |
Data Not Available |
Outpatient Surgery |
Data Not Available |
Prescription Drugs
Generic Rx |
Data Not Available |
Preferred Brand Rx |
Data Not Available |
Non Preferred Brand Rx |
Data Not Available |
Specialty Drugs
| |