In-network benefits

When you go to a doctor or hospital that accepts this plan, that's called getting your care in-network.

Because this plan is a PPO, it'll share the cost for some services if you go to a doctor or hospital that doesn't take this plan. That's called getting your care out-of-network. Those benefits are listed on a separate table below.

Your in-network deductible

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

  • $6,750 for an individual
  • $13,500 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 physician Anytime $25
Office visit to a specialist with a referral Before deductible
All costs
After deductible $0
Laboratory and diagnostic services Lab tests Before deductible All costs
After deductible $0
Radiology services like X-rays, EKGs and ultrasounds

Allergy testing and shots

Imaging services like MRIs
Before deductible All costs
After deductible $0
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 deductible $0
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 $0
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 deductible $0
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 deductible $0
Mental health/substance abuse Care you get at a mental health or substance abuse facility as an inpatient Before deductible All costs
After deductible $0
Office visit to an outpatient mental health or substance abuse facility Before deductible All costs
After deductible $0

Out-of-network benefits

What you'll pay if you go to a doctor or hospital that doesn't accept this plan.

Your out-of-network deductible

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

  • $13,500 for an individual
  • $27,000 for a family (two or more members)
What we call it What it is When you pay What you pay
Preventive services

For adults and dependents under age 19
Exams, prescriptions, tests and shots you get when you’re well to prevent illness and injury

Anytime All costs
Pediatric services

For dependents under age 19
Check-ups children age 18 and younger get when they’re well Anytime All costs
Vision care for children age 18 and younger: Eye exam and glasses or contacts
Once a year All costs above approved amount
Ambulatory services Office visit to your primary care physician Anytime All costs
Office visit to a specialist with a referral Anytime All costs
Laboratory and diagnostic services Lab tests Before deductible All costs
After deductible $0
Radiology services like X-rays, EKGs and ultrasounds

Imaging services like MRIs
Before deductible All costs
After deductible $0
Allergy testing and shots Anytime All costs
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
Before deductible All costs
After deductible $0
Care you get when you deliver your baby in the hospital
Before deductible All costs
After deductible $0
Emergency services Emergency room
Before in-network deductible All costs
After in-network deductible $0
Transportation by ambulance Before in-network deductible All costs
After in-network 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 $0
Hospice care Anytime All costs
Other services, like inpatient and outpatient surgery, chemotherapy and sleep studies Before deductible All costs
After deductible $0
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 deductible $0
Mental health/substance abuse Care you get at a mental health or facility as an inpatient or outpatient Before deductible All costs
After deductible $0
Care you get at a substance abuse facility as an inpatient or outpatient Anytime All costs