Summary of Health Benefits

DeductibleOut of PocketPreventative Care

Hospital Services Prescription Services Emergency Services

Mental Health Services Other Services Doctor’s Services

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In Networkcost

$###

Plan Year Deductible

Out of Networkcost

$###What is a Network? Health Insurance companies maintain networks consisting of specific hospitals, doctors and other medical providers they have made prior arrangements and relationships with. You should always try to use a provider in network to ensure coverage and a lower deductible.

What is a Network? Health Insurance companies maintain networks consisting of specific hospitals, doctors and other medical providers they have made prior arrangements and relationships with. You should always try to use a provider in network to ensure coverage and a lower deductible.

The amount you must pay in a year before you become eligible for insurance benefits.

In Networkcost

$####

Plan Year Out-of-Pocket

Out of Networkcost

$####

The maximum amount you are obligated to pay out-of-pocket each year.

Preventative Care 100% of deductible is waived for In-Network and Out-of –Network preventative care for

Doctor’s Services

Office Visits Chiropractic$500 max per year

Allergy

In Network##% covered

after deductible##% covered

after deductible##% covered

after deductible

Out of Network

##% R&C after deductible

##% R&C after deductible

##% R&C after deductible

Health Plans will look at what is Reasonable and Customary for doctors in your area and base your reimbursement on that amount.

Health Plans will look at what is Reasonable and Customary for doctors in your area and base your reimbursement on that amount.

Emergency Services

Emergency Roomand ER Physician

In Network ##% after deductible

Out of Network##% R&C costs after deductible

Health Plans will look at what is Reasonable and Customary for doctors in your area and base your reimbursement on that amount.

Health Plans will look at what is Reasonable and Customary for doctors in your area and base your reimbursement on that amount.

Hospital Services

In-PatientSurgical Facility SuppliesRoom and Board

In-PatientNewborn CareMisc. Hospital Charges

Out-Patient

In Network ##% after deductible

##% after deductible

##% after deductible

Out of Network

##% R&C costs after deductible

##% R&C costs after deductible

##% R&C costs after deductible

Health Plans will look at what is Reasonable and Customary for doctors in your area and base your reimbursement on that amount.

Health Plans will look at what is Reasonable and Customary for doctors in your area and base your reimbursement on that amount.

Mental Disorders Substance Abuse

In-PatientTreatment

Out-PatientTreatment

In Network ##% after deductible

##% after deductible

Out of Network ##% R&C costs after deductible

##% R&C costs after deductible

Health Plans will look at what is Reasonable and Customary for doctors in your area and base your reimbursement on that amount.

Health Plans will look at what is Reasonable and Customary for doctors in your area and base your reimbursement on that amount.

Prescription Drug Benefit

Retail, up to ## day supply

##% to $#### combined out of pocket maximum

Mailorder, up to ## day supply

##% to $#### combined out of pocket maximum

Other Services

Private Nursing Duty##% after deductible##% R&C after deductible

Home Health Care 80 Visits##% after deductible##% R&C after deductible

Disagnostic X-ray, Lab(Outpatient and Inpatient)

##% after deductible##% R&C after deductible

Physical TherapyOccupational and speech ($500 max)(Therapy reviewed for medical necessity after 20 visits)

##% after deductible##% R&C after deductible

Ambulance##% after deductible##% R&C after deductible

Durable Medical Equipment$### max per calendar year

##% after deductible##% R&C after deductible