In-Network	Out-of-Network
CALENDAR YEAR DEDUCTIBLE1 (CYD) Unless otherwise indicated, all benefits are subject to CYD.	$7,500 per member
OUT-OF-POCKET MAXIMUM2 (OOP) Once the OOP maximum is met, benefits are provided at 100% for a member for the remainder of the calendar year. This applies to in-network provider services only. There is no Out of Pocket Maximum when out of network providers are used.	$15,000 individual $30,000 family	Unlimited
LIFETIME BENEFIT MAXIMUM	Unlimited

FOOTNOTES

¹ Deductible – the dollar amount of covered services that must be incurred and paid first by a member each calendar year before plan benefits begin.

² Once the OOP maximum is met, benefits are provided at 100% for a member(s) for the remainder of the calendar year. This applies to in-network provider services only. There is no Out of Pocket Maximum when out of network providers are used.

	In-Network	Out-of-Network
COINSURANCE Based on the maximum allowable charges for eligible benefits. Family deductible can be satisfied by one or more covered members during a calendar year.	Plan pays: 80% Your responsibility: 20%	Plan pays: 60% Your responsibility: 40%
TELADOC	No charge to member.	Not covered.
PREVENTATIVE CARE BENEFITS
Well Child Services3	Plan pays: 80% Your responsibility: 20%	Not Covered
Routine Colonoscopy4	Plan pays: 80% Your responsibility: 20%	Plan pays: 60% Your responsibility: 40%
Annual Routine PSA5	Plan pays: 80% Your responsibility: 20%	Plan pays: 60% Your responsibility: 40%
Annual OB/GYN Exam6	Plan pays: 80% Your responsibility: 20%	Not covered.
Annual Routine Pap Smear7	Plan pays: 80% Your responsibility: 20%	Plan pays: 60% Your responsibility: 40%
Mammogram8	Plan pays: 80% Your responsibility: 20%	Plan pays: 60% Your responsibility: 40%

 

PRESCRIPTION DRUG COVERAGE Unlimited Calendar Year Maximum Per Member
Generic 30 day supply	Plan pays all but copayment Your responsibility: $4 copayment9	Plan pays 60% Your responsibility: 40%
Brand	Plan pays: 80% Your responsibility: 20%	Plan pays 60% Your responsibility: 40%

FOOTNOTES

³ Benefits are available, subject to deductible and coinsurance, for a member under the age of seven for physical examinations and appropriate immunizations/vaccinations when services are rendered by an in-network provider. Exams not used during the time periods below do not carry over to the next time period.

Age	Number of Exams
Under age one	four exams from birth to the child's first birthday
Age one	two exams from the child's first birthday to the child's second birthday
Age two through six	one exam per year (determined by the child's birthday)

⁴ Benefits will be provided for one routine colonoscopy every four years for members age 50 and over when provided by an in-network or out-of-network provider, subject to the deductible and coinsurance.

⁵ Benefits will be provided, subject to deductible and coinsurance, for one routine PSA per calendar year when services are rendered by an independent laboratory or other outpatient setting.

⁶ Benefits will be available for one routine OB/GYN exam per calendar year, subject to deductible and coinsurance. Services must be rendered by an in-network physician’s office and billed by the in-network provider. Related pathology, including pap smear, which is provided as a part of the routine OB/GYN exam, will be covered when the services are rendered by an in-network physician’s office and billed by the in-network provider. Related pathology that the physician sends to an independent laboratory will be subject to deductible and coinsurance. No benefit is available for routine OB/GYN exams provided by an out-of-network provider.

⁷ Benefits will be provided for the interpretation of one routine pap smear per calendar year when services are rendered by an independent laboratory or other outpatient setting, subject to deductible and coinsurance.

⁸ Benefits will be provided, subject to deductible and coinsurance, for routine mammography screening provided such examinations are conducted upon the recommendation of the member’s physician. One baseline routine mammogram will be allowed for members between the ages of 35-39. One routine mammogram will be allowed annually for members age 40 and above. All routine mammography screens are subject to deductible and coinsurance.

⁹ Prescription copayment does not apply toward deductible or out-of-pocket maximum.

Benefits will not be provided for any pre-existing condition until a member has completed a waiting period of at least 12 months. A pre-existing condition is defined in the contract as “An illness, injury, pregnancy or any other medical condition which existed at any time preceding the effective date of coverage under this contract for which: Medical advice or treatment was recommended by, or received from, a provider of health care services; or symptoms existed which would cause an ordinarily prudent person to seek diagnosis, care or treatment.”

Maternity Benefits will be available after a member’s coverage on a family contract has been in effect for nine consecutive months. Individual coverage has NO maternity benefits.