in-network
Annual Deductible$0 single/$0 all other coverage levels
Annual Out-of-Pocket Maximum$1,500 single/$3,000 all other coverage levels
Lifetime Maximum BenefitUnlimited
General Medical Expenses
Primary & Specialist Doctor Office Visit$25 copay
Inpatient Hospital Care3 (requires preauthorization)
Hospitalization $500 per admission
Inpatient Physician and Surgeon Services100% covered
Inpatient Lab and X-ray100% covered
Maternity and Delivery Services & Newborn Nursery Services2
100% covered
Outpatient Care
Outpatient Surgery$100 per procedure
Outpatient X-ray & Laboratory Services$10 copay
Emergency Services
Emergency Room$100 copay if not admitted to hospital/$0 if admitted directly to hospital
Urgent Care Clinic $20 copay
Ambulance Services $50 per trip
Preventative Care
Annual Physical Exam & Immunizations100% covered
Well-Baby & Well-Child Exams & Immunizations100% covered
Well-Woman Exam100% covered
Other Preventive Care100% covered
Mental Health, Substance Abuse Care
Mental Health: Outpatient Coverage$10 copay for group visit; $20 copay for single visit
Mental Health: Inpatient Coverage100% covered
Detox Rehab: Outpatient Coverage$5 copay for group visit; $20 copay for single visit
Detox Rehab: Inpatient Coverage100% covered
Other Benefits
Durable Medical Equipment20% coinsurance
Home Health Care100% covered (up to 100 visits per calendar year)
Skilled Nursing Facility100% covered (up to 100 days per benefit period)
Chiropractic Services$10 copay (up to 30 office visits per calendar year) plus a $50 allowance per calendar year for chiropractic appliances
Covered Infertility Treatment 50% coinsurance
Prescription DrugsPrescription drug coverage is provided through Kaiser.