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Options
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Calendar Year Deductibles
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Copayment Amounts
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Calendar Year Out-of-Pocket Maximum/Security Provisions
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**Coinsurance
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Individual In-Network
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Individual Out-of-Network
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Family In-Network
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Family Out-of-Network
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Office Visit (Includes lab and x-ray up to annual max of $750*)
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Emergency Care*
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Individual In-Network
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Individual Out-of-Network
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Family In-Network
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Family Out-of-Network
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In-Network | Out-of-Network | |||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Plan Pays |
You Pay |
Plan Pays |
You Pay |
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| Plan I |
$250
|
$500
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$750
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$1,500
|
$25 | $100 |
$3,000
|
$6,000 | $6,000 | $12,000 |
85%
|
15% | 75% | 25% |
| Plan II |
$500
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$1,000
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$1,500
|
$3,000
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| Plan III |
$1,000
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$2,000
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$3,000
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$6,000
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| Plan IV |
$1,500
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$3,000
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$4,500
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$9,000
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| Plan V |
$2,500
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$5,000
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$7,500
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$15,000
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| PlanVI |
$3,500
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$7,000
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$10,500
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$21,000
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PlanVII |
$5,000
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$10,000
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$15,000
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$30,000
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| PlanVIII |
$10,000
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$20,000
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$30,000
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$60,000
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*All other medical-surgical expenses will be subject to deductible and coinsurance amounts
85% subject to the deductible
**Percentages apply to covered expenses after calendar year deductibles are met
