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Standard Option Plan

Summary of Benefits

2018 Standard Option – Summary of Benefits

MEDICAL BENEFITS IN-NETWORK YOU PAY OUT OF NETWORK YOU PAY
PHYSICIAN CARE
Family Physicians $30 per office visit 45%
Specialists $30 per office visit 45%
Well-Child Visits Nothing 45%
Annual Physicals Nothing 45%
Adult/Child Immunizations Nothing Nothing
HOSPITAL CARE
Inpatient $200 per confinement
20% for ancillary services
$400 per confinement
45% for room & board and ancillary services
Outpatient 20% 45%
MATERNITY
Hospital Nothing $400 per confinement
45% for room & board and ancillary services
Obstetrical Care nothing 45%
OTHER BENEFITS
Cancer Screenings Nothing 45%
Surgery 20% 45%
Laboratory Services 20%, Nothing at LabCorp
Or Quest Diagnostics
45%
Accidental Injury Care Nothing (within 24 hours) Nothing (within 24 hours)
Calendar Year Deductible $400 per person $400 per person
Out-of-Pocket Maximum $7,000 per person; $14,000 per family $9,500 per person; $19,000 per family
PRESCRIPTION DRUGS
Retail
(up to a 30-day supply)
$12 generic
35% preferred name brand
($150 max)
50% non-preferred name brand ($300 max)
$12 generic
35% preferred name brand
($150 max)
50% non-preferred name brand ($300 max)
Mail Order
(up to a 90-day supply)
$20 generic
35% preferred name brand
($300 max)
50% non-preferred name brand ($600 max)
$20 generic
35% preferred name brand
($300 max)
50% non-preferred name brand ($600 max)