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|
| BENEFITS |
SMARTSENSE PLUS |
| Calendar Year Deductible |
Your Choices (choose from 4 low-cost plans) |
| Individual |
$1,000
$1,000 |
$2,000
$2,000 |
$3,500
$3,500 |
$6,000
$6,000 |
Network
Non-Network |
| Family |
$2,000
$2,000 |
$4,000
$4,000 |
$7,000
$7,000 |
$12,000
$12,000 |
Network
Non-Network |
| Network Coinsurance Options |
30% |
30% |
30% |
30% |
|
| Calendar Year Out-of-Pocket Maximum |
Add your chosen Deductible to the amount below |
| Individual |
$3,500
$7,500 |
$3,500
$7,500 |
$3,500
$7,500 |
$3,500
$7,500 |
Network
Non-Network |
| Family |
$7,000
$15,000 |
$7,000
$15,000 |
$7,000
$15,000 |
$7,000
$15,000 |
Network
Non-Network |
| How family deductibles and family out-of-pocket maximums work |
Once one family member reaches their individual deductible or out-of-pocket maximum, the remaining amount of the family deductible or out-of-pocket maximum needs to be met by one or more other family members. The family deductible or out-of-pocket maximum can be met by the family combined. |
| Lifetime Maximum |
Unlimited |
| Covered Services |
Your share of costs (after deductible, unless waived) |
| Doctors' Office Visits |
NETWORK: First 3 Office Visits (per member) $30 Copay, deductible waived
Additional Office Visits: 30% Coinsurance
NON-NETWORK: 50% Coinsurance |
| Professional and Diagnostic Services (X-ray,lab,anesthesia,surgeon,etc.) |
NETWORK: 30% Coinsurance
NON-NETWORK: 50% Coinsurance |
Inpatient Services
(overnight hospital/facility stays) |
NETWORK: 30% Coinsurance
NON-NETWORK: All charges except $650 per day |
Outpatient Services
(No overnight hospital/facility stays) |
NETWORK: 30% Coinsurance
NON-NETWORK: All charges except $380 per day |
| Emergency Room Services |
NETWORK: 30% Coinsurance plus $100 Emergency Room copay (copay waived if admitted)
NON-NETWORK: 30% Coinsurance plus $100 Emergency Room copay (copay waived if admitted) |
| Preventive Care Services |
NETWORK: 0% Coinsurance, not subject to deductible
NON-NETWORK: 50% Coinsurance |
| Maternity |
Not Covered |
Optional Coverages
(for additional cost) |
Dental, Life |
| Prescription Drugs |
|
Retail Drugs
(and Mail Order Drugs
when available) |
NETWORK: Standard Drug Coverage
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 |
Optional Drug Coverage
(when available) |
NETWORK: Upgrade Drug Coverage
Tier 1 (Generic Drugs): $15 Copay
$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 $500 annual deductible.
NON-NETWORK: Not Covered |
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