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.