|
|
| Active Start 35 Generic Rx |
In-Network |
Out-Of-Network |
 |
Annual Deductible |
None |
None |
|
Annual Out-Of-Pocket Limit |
Individual: $7,500 |
Individual: $10,000 |
|
Lifetime Maximum |
$6,000,000 |
$6,000,000 |
|
Office Visits |
$35 |
50% |
|
Prescription Drugs |
$10 Generic |
$10 Generic |
|
Laboratory and Radiology |
40% |
50% |
|
Annual Physical Exam |
$35 |
Not Covered |
|
Annual OB-GYN Exam |
$35 |
Not Covered |
|
Prenatal / Postnatal Maternity |
Not Applicable |
Not Applicable |
|
Well Baby Care |
$35 |
Not Covered |
|
Outpatient Surgery |
40% plus $500 per visit |
50% ($250 maximum benefit per day) |
|
Emergency Room |
$35 (waived if admitted), then 40% |
$35 (waived if admitted), then 40% |
|
Ambulance |
40% |
40% |
|
Home Health Care |
40% (90 visits per year) |
Not Covered |
|
Mental Health Services |
40% (20 visits per year) |
Not Covered |
|
Chiropractic Care |
40% (12 visits per year) |
50% (maximum benefit $25 per visit, 12 visits per year) |
|
Acupuncture / Acupressure |
50% (maximum benefit $25 per visit, 12 visits per year) |
50% (maximum benefit $25 per visit, 12 visits per year) |
|
Inpatient Co-payment |
40% plus $500 per admission |
50% ($250 maximum benefit per day) |
| |
Maternity Care |
Not Covered |
Not Covered |
|
Inpatient Mental Health |
40% plus $500 per admission |
50% ($250 maximum benefit per day) |
|
Chemical Dependency |
40% plus $500 per admission |
50% ($250 maximum benefit per day) |
|
| |
|
QUOTE
APPLY ONLINE
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PLAN
BENEFITS PDF
EXCLUSIONS |
| |
|
|
Individual Family