| Benefit |
Copay Select
|
Copay Saver
|
| Network type |
Preferred Network |
Preferred Network |
|
Calendar-Year Deductible Choices (maximum 2 per family, per calendar year)
|
$500, $1000, $1500, $2500 |
$2000 |
| Coinsurance (per covered person per calendar year) |
80/20 to $10,000 then 100% |
80/20 to $15000 then 100% |
| Lifetime Maximum Benefit |
$3 million |
$3 million |
| Room and Board, Intensive Care Unit, Operating Room, Recovery Room and Professional Fees of Doctors, Surgeons, Nurses |
80% after deductible |
80% after deductible |
| Other Covered Inpatient Services |
80% after deductible |
80% after deductible |
| Surgeon, Assistant Surgeon, and Facility Fees |
80% after deductible |
80% after deductible |
| Hemodialysis, Radiation, Chemotherapy, and Organ Transplant Drugs, Cat Scans, MRIs |
80% after deductible |
80% after deductible |
| Outpatient X-ray and Lab (performed in the doctor's office or elsewhere) |
80% after dedictible |
80% after deductible if performed within 14 days of surgery or confinement |
| Emergency Room Fees |
80% after deductible - additional $100 copay for illness if not admitted |
80% after deductible - additional $500 Copay if not admitted |
| Doctors Office Visit |
For history and exam: $25 Copay, then 100% (not subject to deductible) |
For history and exam: $35 Copay, then 100% (maximum 2 visits per person per year) Other services (not covered) |
| Mammography, Pap Smear, and PSA testing |
For history and exam: $25 copay, then 100% |
80% after deductible |
| Adult Preventive Care (age 19 or older) |
For other services, performed in or out of doctor's office, including but not limited to, X-ray and Lab, subject to the deductible, then 80% |
Not covered |
| Well Child care and immunizations |
Same as above |
Same as above |
| Outpatient Generic drugs |
$15 copay |
Not Covered |
| Outpatient name brand drugs |
$100 per person, calendar year deductible - then $30 copay for preferred, $60 Copay for non-preferred (if generic is available, Name Brand reimbursed at Generic price. |
Not Covered |
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