|
|
| BENEFITS |
ClearProtection Plus |
Calendar Year Deductible
(choose from 3 low-cost plans) |
All covered network and non-network services apply toword the deductibles below |
| Individual |
$1,000
or
$4,500 |
$3,300
or
$6,800 |
$5,000
or
$8,500 |
For Inpatient/Surgical and Emergency Room Services
or
For Outpatient/Professional and Diagnostic Services |
| Family |
$2,000
or
$9,000 |
$6,600
or
$13,600 |
$10,000
or
$17,000 |
For Inpatient/Surgical and Emergency Room Services
or
For Outpatient/Professional and Diagnostic Services |
| Network Coinsurance Options |
40%
0% |
40%
0% |
40%
0% |
For Inpatient/Surgical and Emergency Room Services
For Outpatient/Professional and Diagnostic Services |
| Calendar Year Out-of-Pocket Maximum |
All covered services, in any combination, apply toward your out-of-pocket maximum below.
This is the maximum you'll pay for most network covered services each calendar year; then the plan pays 100% |
| Individual |
$4,500 |
$6,800 |
$8,500 |
Network or Non-Network
(These amounts include the deductible) |
| Family |
$9,000 |
$13,600 |
$17,000 |
Network or Non-Network
(These amounts include the deductible) |
| Lifetime Maximum |
Unlimited |
| Covered Services |
Your share of costs (after deductible, if applicable) |
| Doctors' Office Visits |
NETWORK: First 2 office visits (per member): $40 copay, deductible waived
Additional office visits: 100% of negotiated fee; then 0% coinsurance after out-of-pocket max is met
NON-NETWORK: 100% Coinsurance; then 50% coinsurance after out-of-pocket maximum is met |
| Professional and Diagnostic Services (X-ray,lab,anesthesia,surgeon,etc.) |
NETWORK: Inpatient 40% Coinsurance
Outpatient: 100% of negotiated fee; then 0% coinsurance after out-of-pocket max is met
NON-NETWORK: Inpatient: 50% Coinsurance
Outpatient: 100% coinsurance; then 50% coinsurance after out-of-pocket maximum is met |
Inpatient Services
(overnight hospital/facility stays) |
NETWORK: 40% Coinsurance
NON-NETWORK: All charges except $650 per day |
Outpatient Services
(No overnight hospital/facility stays) |
NETWORK: 40% Coinsurance
Other Services: 100% of negotiated fee; then 0% coinsurance after out-of-pocket max is met
NON-NETWORK: All charges except $380 per day |
| Emergency Room Services |
NETWORK: 40% Coinsurance plus $100 Emergency Room copay (copay waived if admitted)
NON-NETWORK: 40% Coinsurance plus $100 Emergency Room copay (copay waived if admitted) |
| Preventive Care Services |
NETWORK: 0% Coinsurance, not subject to deductible
NON-NETWORK: 100% Coinsurance; then 50% Coinsurance after out-of-pocket max is met |
| Maternity |
Not Covered |
Optional Coverages
(for additional cost) |
Dental, Life |
Prescription Drugs:
Retail Drugs (and Mail Order Drugs when available) |
NETWORK:
Tier 1 (Generic Drugs): $15 Copay
$7,500 annual Prescription Drug deductible per member applies before the following:
Tier 2 (Formulary Brand name drugs): $40 Copay
Tier 3 (Non-formulary Brand name drugs): $60 Copay
Specialty: 25% Coinsurance up to $2,500 annual Prescription Drug out-of-pocket max (the most you'll have to pay),
for network only and in additional to $7,500 annual deductible.
NON-NETWORK: Not Covered |
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