| Lifetime Maximum |
Participating Provider
| $5,000,000/member |
Non-participating Provider
| $5,000,000/member |
Annual Out-of-Pocket Maximum
(includes deductible) |
Participating Provider
| $3,000/single, $5,500/family All covered benefits for medical and drug combined |
Non-participating Provider
| $3,000/single, $5,500/family All covered benefits for medical and drug combined |
| Annual Deductible |
Participating Provider
| $2,400/single, $4,500/family All covered benefits for medical and drug combined |
Non-participating Provider
| $2,400/single, $4,500/family All covered benefits for medical and drug combined |
| Office Visits |
Participating Provider
| After deductible, 50% of negotiated fee |
Non-participating Provider
| Not covered |
Professional Services
(other office visits, X-ray, lab, anesthesia, surgeon, etc.) |
Participating Provider
| 50% of negotiated fee |
Non-participating Provider
| Not covered |
| Hospital Inpatient/Outpatient |
Participating Provider
| 50% of negotiated fee |
Non-participating Provider
| Not covered |
| Emergency Services |
Participating Provider
| 50% of negotiated fee3 |
Non-participating Provider
| 50% of customary & reasonable for first 48 hours plus 100% of excess; no coverage after 48 hours |
Maternity
(after deductible) |
Participating Provider
| 50% of negotiated fee |
Non-participating Provider
| Not covered |
| Preventive Care |
Participating Provider
| Healthy
Check Centers: $25 or $75 copay for basic screenings; routine
mammogram, PSA and cancer screening, ordered by physician:
50% of negotiated fee; well-child, 50% of negotiated fee
(deductible waived) |
Non-participating Provider
| Not covered |
| Ambulance |
Participating Provider
| 50% of negotiated fee |
Non-participating Provider
| Emergency only, then 50% of customary & reasonable |
| Physical and Occupational Therapy; Chiropractic Services |
Participating Provider
| 50% of negotiated fee limited to 12 visits/year |
Non-participating Provider
| Not covered |
| Acupuncture/Acupressure |
Participating Provider
| All charges except $25/visit; limited to 12 visits/year combined |
Non-participating Provider
| Not covered |
Drug Benefits
(retail or mail order: 30-day supply) |
Participating Provider
| Combined
with medical deductible. 15% of negotiated fee, generic;
35% of negotiated fee, brand; 30% of negotiated fee, self-administered
injectables except insulin |
Non-participating Provider
| Not covered |
EPO (7892) 
