|
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 |
$1,500
|
$3,000
|
$4,500
|
$9,000
|
75% | 75% |
$3,000 |
No Limit | $9,000 | No Limit |
75%
|
25% | 50% | 50% |
| Plan II |
$2,500
|
$5,000
|
$7,500
|
$15,000
|
||||||||||
| Plan III |
$3,500
|
$7,000
|
$10,500
|
$21,000
|
||||||||||
| Plan IV |
$5,000
|
$10,000
|
$15,000
|
$30,000
|
||||||||||
