In-network benefits

When you go to a doctor or hospital that accepts this plan, that's called getting your care in-network. Other care isn't covered except:

  • When you get a referral from your primary care physician and authorization from your plan.
  • In an emergency.

Why are there two deductibles?

When you're in the hospital or another facility as an inpatient, the bills you pay will count toward your inpatient deductible. Most other services — including doctor office visits, prescription drugs and emergency care — will count toward your outpatient deductible.

You'll never pay the full amount of both deductibles

Your out-of-pocket maximum will cap your costs at:

  • $6,350 for an individual
  • $12,700 for a family

Your deductibles

Be sure to compare your before and after deductible costs. It makes a big difference in what you have to pay. This plan has two deductibles:

Outpatient deductible:

  • $6,350 for an individual
  • $12,700 for a family (two or more members)

Inpatient deductible:

  • $4,400 for an individual
  • $8,800 for a family (two or more members)
What we call it What it is When you pay What you pay
Preventive services
Exams, prescriptions, tests and shots you get when you’re well to prevent illness and injury

Anytime $0
Pediatric services
Children can get pediatric benefits until the end of the calendar year in which they turn 19.
Check-ups children get when they’re well
Anytime $0
Vision care for children: Eye exam and glasses or contacts
Once a year $0
Ambulatory services Office visit to your primary care doctor
Before deductible
All costs
After deductible $0
Office visit to a specialist
Before deductible
All costs
After deductible $0
Laboratory and diagnostic services Includes:
  • Lab tests
  • Radiology services like X-rays and EKGs
  • Allergy testing and shots
  • Imaging services like MRIs
Before deductible All costs
After outpatient deductible $0
After inpatient deductible 40%
What we call it What it is When you pay What you pay
Maternity and newborn care

Doctor office visits while pregnant

  • Tests and ultrasounds you get during the visit are billed under laboratory services
Anytime $0
Care you get when you deliver your baby in the hospital
Before deductible All costs
After outpatient deductible $0
After inpatient deductible 40% + $500
Emergency services Emergency room Before deductible All costs
After deductible $0
Transportation by ambulance Before deductible
All costs
After deductible $0
Urgent care
Before deductible All costs
After deductible $0
Hospitalization and other services Care you get when you’re in the hospital for at least one night Before deductible All costs
After deductible 40% + $500
Hospice care
Before deductible All costs
After deductible $0
Most other services, like inpatient and outpatient surgery, chemotherapy, home health care and sleep studies Before deductible All costs
After outpatient deductible $0
After inpatient deductible 40%
What we call it
What it is
When you pay
What you pay
Rehabilitative and habilitative services and devices
Services that help you recover from or manage an injury or illness, like:
  • Physical and occupational therapy
  • Spinal manipulation from a chiropractor
  • Speech therapy
  • Diabetes supplies
Before deductible All costs
After deductible $0
Durable medical equipment, like a wheelchair, walker or oxygen tank Before deductible All costs
After outpatient deductible $0
After inpatient deductible 50%
Mental health/substance abuse Care you get at a mental health or substance abuse facility as an inpatient Before deductible All costs
After deductible 40% + $500
Office visit to an outpatient mental health or substance abuse facility Before deductible All costs
After deductible $0