Maximizer PPO Benefits
| |
In Network Provider |
Out of Network Provider |
Plan year deductible
(family deductible is 3x the individual) |
$1,000 / $2,500 / $5,000 |
Out-of-Pocket Maximum, Per Member
(after deductible) |
$5,000 |
$10,000 |
| Plan Year Essential Benefit Maximum |
$2,000,000 |
| Preventive Care - The deductible is waived for in-network preventive care. |
In Network Provider |
Out of Network Provider |
| Annual women's exam - Pap, pelvic, breast |
$0* |
50% |
| Women's routine mammogram |
$0* |
50% |
| Well-baby care |
$0* |
Not covered |
| Routine Physical Exams |
$0* |
Not covered |
| Immunizations |
$0* |
Not covered |
| Professional Services |
| Office Visits |
First 6 at $20 copay* |
50% |
Alternative care ($1,000 per plan year limit)
Chiropractic, naturopathic and acupuncture |
$20 copay* |
50% |
| Facility and Ancillary Services |
| Hospital - Inpatient and outpatient surgery; room, ancillary and physician charges; skilled nursing facility care |
30% |
50% |
| Maternity - All pre/post office visits and doctor delivery; hospital charges |
30% |
50% |
Mental health — Inpatient, outpatient, residential
(see limitations and exclusions) |
30% |
50% |
Alcohol / Mental Health Treatment
Inpatient, outpatient, residential combined |
30% |
50% |
| Lab and X-ray services; rehabilitation services; medical supplies and devices; in-hospital care; home healthcare |
30% |
50% |
Vision
(see limitations and exclusions) |
Not covered |
| Emergency Services |
| Urgent care |
First 6 at $20 copay* |
50% |
| Emergency room (deductible applies) |
30% after $100 copay |
| Ambulance ($5,000 per plan year limit) |
30% |
| Other Benefits |
| Prescription services |
$2 value tier, $15 generics or 50% brand* |
| Accident benefit |
Deductible waived for treatment completed within 90 days of accident. |
*Deductible waived
** Deductible waived for first six medical home, office or urgent care visits per plan year. First six in-network visits do not include home or office visits for mental health, alcohol treatment, family planning or biofeedback. Subsequent visits are subject to the deductible and co-insurance.
Note: This is a benefit summary only. For a complete description of benefits, refer to your Policy. |
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