| Options |
Calendar Year Deductibles |
Copayment Amounts |
Calendar Year Out-of-Pocket Maximum/Security Provisions |
*Coinsurance |
||||||||||
|
|
Individual In-Network |
Individual Out-of-Network |
Family In-Network |
Family Out-of-Network |
Office Visit (Physician consultation only) * |
Emergency Care* |
Individual In-Network |
Individual Out-of-Network |
Family In-Network |
Family Out-of-Network |
In-Network |
Out-of-Network |
||
Plan
Pays |
You
Pay |
Plan
Pays |
You
Pay |
|||||||||||
| Plan I |
$1,150 |
$2,300 |
$2,300 |
$4,600 |
90% of Allowable Amount after calendar year deductible |
$3,000 |
$6,000
| $6,000
| $12,000 |
90% |
10%
|
70%
|
30%
| |
| Plan II |
$1,750 |
$3,500 |
$3,500 |
$7,000 |
||||||||||
| Plan III |
$2,500 |
$5,000 |
$5,000 |
$10,000 |
||||||||||
| Plan IV |
$1,150 |
$2,300 |
$2,300 |
$4,600 |
75%
of Allowable Amount after calendar year deductible |
$3,000 |
$6,000
| $6,000
| $12,000 |
75% |
25% |
60% |
40%
| |
Plan
V |
$1,750 |
$3,500 |
$3,500 |
$7,000 |
||||||||||
| Plan VI |
$2,500 |
$5,000 |
$5,000 |
$10,000 |
||||||||||
|
Plan VII |
$3,500 |
$7,000 |
$7,000 |
$14,000 |
100%
of Allowable Amount after calendar year deductible |
$3,500 |
$7,000
| $7,000
| $14,000 |
100% |
0% |
100% |
0%
| |
| Plan VIII |
$5,000 |
$10,000 |
$10,000 |
$20,000 |
$5,000 |
$10,000
| $10,000
| $20,000 |
100% |
0% |
100% |
0%
| ||
