| 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 |
Emergency Care* |
Individual In-Network |
Individual Out-of-Network |
Family In-Network |
Family Out-of-Network |
In-Network | Out-of-Network | |||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Plan I | None |
None |
None |
None |
50% of Allowable Amount | 50% of Allowable Amount |
$10,000/$20,000 |
$20,000/$40,000 | 50% |
50% |
50% | 50% | ||
| Plan II | $20,000/$40,000 |
$40,000/$80,000 |
||||||||||||
| Plan III | $30,000/$60,000 |
$60,000/$120,000 |
||||||||||||
Lifetime maximum is $5 million per participant.