IN-NETWORK |
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|---|---|---|
| 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 Benefit | Unlimited | |
| General Medical Expenses | ||
| Primary & Specialist Doctor Office Visit | $25 copay | |
| Inpatient Hospital Care3 (requires preauthorization) | ||
| Hospitalization | $500 per admission | |
| Inpatient Physician and Surgeon Services | 100% covered | |
| Inpatient Lab and X-ray | 100% 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 | |
| Preventive Care | ||
| Annual Physical Exam & Immunizations | 100% covered | |
| Well-Baby & Well-Child Exams & Immunizations | 100% covered | |
| Well-Woman Exam | 100% covered | |
| Other Preventive Care | 100% covered | |
| Mental Health, Substance Abuse Care | ||
| Mental Health: Outpatient Coverage | $10 copay for group visit; $20 copay for single visit | |
| Mental Health: Inpatient Coverage | 100% covered | |
| Detox Rehab: Outpatient Coverage | $5 copay for group visit; $20 copay for single visit | |
| Detox Rehab: Inpatient Coverage | 100% covered | |
| Other Benefits | ||
| Durable Medical Equipment | 20% coinsurance | |
| Home Health Care | 100% covered (up to 100 visits per calendar year) |
|
| Skilled Nursing Facility | 100% 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 Drugs | Prescription drug coverage is provided through Kaiser. | |