| Lifetime
Maximum |
In-Network
|
$5,000,000.00 |
Out-of-Network
|
$5,000,000.00 |
| Out
of Pocket Maximum |
In-Network
|
$7,500.00
In and Out of Network Combined |
Out-of-Network
|
$7,500.00
In and Out of Network Combined |
| Annual
Deductible |
In-Network
|
$0 |
Out-of-Network
|
$0 |
| Office
Visits |
In-Network
|
$40
CoPay |
Out-of-Network
|
50%
of negotiated fee plus 100% of charges in excess of negotiated
fee 1 |
| Professional
Services |
In-Network
|
40%
of negotiated fee |
Out-of-Network
|
50%
of negotiated fee plus 100% of charges in excess of of negotiated
fee |
| Inpatient
Hospital Services (Includes organ and tissue transplants) |
In-Network
|
40%
of negotiated fee plus $400 copay per day/4 day max per admission
2,4,5 |
Out-of-Network
|
All
charges except $650 per day |
| Outpatient
Hospital Services/Ambulatory Surgical Center |
In-Network
|
40%
of negotiated fee plus $400 copay per outpatient surgery admit
2,4,5 |
Out-of-Network
|
All
charges except $380 per day |
| Emergency
Care |
In-Network
|
40%
of negotiated fee 3 |
Out-of-Network
|
40%
of C&R for first 48 hours plus 100% of charges in excess of
C&R. After 48 hours all charges in excess of $650 per day
3,7 |
| Maternity |
In-Network
|
Not
Covered |
Out-of-Network
|
Not
Covered |
| Preventive
Care/Healthy Check Center |
In-Network
|
$25
or $75 option |
Out-of-Network
|
Not
covered |
Preventive
Care
|
In-Network
|
$40
office visit plus 40% of negotiated fee for well-baby and
well-child thru age 6
$40 office visit plus 40% of negotiated fee for Covered Services
other than the Office Visit for Annual Pap exam Breast exams
Mammogram testing and appropriate screening |
Out-of-Network
|
All
charges in excess of 50% of negotiated fee for well-baby and
well-child thru age 6
All Charges in excess of 50% of negotiated fee |
| Ambulance
Service |
In-Network
|
40%
of negotiated fee |
Out-of-Network
|
All
charges in excess of 50% of negotiated fee |
| Physical
Therapy, Occupational Therapy/Chiro |
In-Network
|
40%
of negotiated fee; limited to 12 visits/year, participating
and non-participating combined |
Out-of-Network
|
All
charges except $25 per visit |
| Acupuncture/Acupressure |
In-Network
|
All
charges except $25 per visit; limited to 24 visits/year, participating
and non-participating combined |
Out-of-Network
|
All
charges except $25 per visit; limited to 24 visits/year, participating
and non-participating combined |
| Prescription
Drug Benefit |
In-Network
|
$10
Generic CoPay, Right Plan Generic Prescription Formulary 6
Click
here to view the Right Plan generic prescription formulary |
Out-of-Network
|
50%
of Drug Limited Fee schedule less the copay as stated for
participation pharmacies |
