|
Package 1 |
Package 2 |
| In-network |
Out-of-network |
In-network |
Out-of-network |
| Aqua Allowance (Unused amounts roll over up to $1000 maximum. Does not apply to deductible.) |
$500 single/$1,000 family for in-network and out-of-network combined. For all covered services except drug. |
$500 single/$1,000 family for in-network and out-of-network combined. For all covered services except drug. |
| Deductible |
$500 single / $1,000 family |
$1,000 single / $2,000 family |
| Coinsurance |
20% |
50% |
20% |
50% |
| Out-of-Pocket Maximum (Deductible and Aqua Allowance do not apply) |
$2,500 single/$5,000 family for member payments |
$10,000 single/$20,000 family for member payments |
$3,500 single/$7,000 family for member payments |
$10,000 single/$20,000 family for member payments |
| Gym/Acupuncture/Massage |
$250 single/$500 family annual benefit |
Not covered |
$250 single/$500 family annual benefit |
Not covered |
| Office Visit |
Deductible & 20% |
Deductible & 50% |
Deductible & 20% |
Deductible & 50% |
| Well Child Visits |
$0 – not subject to deductible |
Deductible & 50% |
$0 – not subject to deductible |
Deductible & 50% |
| Vision Exam |
Deductible & 20% |
Deductible & 50% |
Deductible & 20% |
Deductible & 50% |
| Lab Tests / Services |
Deductible & 20% |
Deductible & 50% |
Deductible & 20% |
Deductible & 50% |
| X-rays |
Deductible & 20% |
Deductible & 50% |
Deductible & 20% |
Deductible & 50% |
| Emergency Room / Ambulance |
Deductible & 20% |
Deductible & 50% |
Deductible & 20% |
Deductible & 50% |
| In-patient Hospital Stay |
$0 – not subject to deductible |
Deductible & 50% |
$0 – not subject to deductible |
Deductible & 50% |
| Outpatient Surgery |
Deductible & 20% |
Deductible & 50% |
Deductible & 20% |
Deductible & 50% |
| Durable Medical Equipment (DME) |
Deductible & 20% up to $1,000 limit |
Deductible & 50% up to $1,000 aggregate limit |
Deductible & 20% up to $1,000 limit |
Deductible & 50% up to $1,000 aggregate limit |
| Drug Coverage - Retail |
$7 Copay - Generics (Discount for brand drugs) |
Not covered |
$7 Copay - Generics (Discount for brand drugs) |
Not covered |
| Drug Coverage - Mail |
$17.50 Copay – 90 day supply of Generics (Discount for brand drugs) |
Not covered |
$17.50 Copay – 90 day supply of Generics (Discount for brand drugs) |
Not covered |
