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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 in-network deductible is:

  • $1,400 for an individual
  • $2,800 for a family (two or more members)
What we call it What it is When you pay What you pay
Preventive care 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.
Checkups children get when they're well. Anytime
$0
Vision care for children: Exam and glasses or contacts. Once a year $0
Ambulatory services Office visit to your primary care doctor Before deductible
All costs
After deductible
$30
Office visit to a specialist
Before deductible
All costs
After deductible $50
Laboratory and diagnostic services

Includes:

  • Lab tests
  • Radiology services like X-rays, EKGs and ultrasounds
  • Allergy testing and shots
Before deductible All costs
After deductible 30%
Imaging services like MRIs Before deductible All costs
After deductible 20% + $200
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
20% + $500
Emergency services
Emergency room visit
Before deductible
All costs
After deductible
20% + $250
Transportation by ambulance Before deductible All costs
After deductible 20%
Urgent care center visit
Before deductible
All costs
After deductible 20% + $75
Hospitalization and other services
Care you get when you’re in the hospital for at least one night Before deductible
All costs
After deductible 20% + $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 deductible 20%
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 20%
Durable medical equipment, like a wheelchair, walker or oxygen tank Before deductible All costs
After 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 20% + $500
Office visit to an outpatient mental health or substance abuse facility
Before deductible All costs
After deductible 20%

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 out-of-network deductible is:

  • $2,800 for an individual
  • $5,600 for a family (two or more members)
What we call it What it is When you pay What you pay
Preventive care Exams, prescriptions, tests and shots you get when you're well to prevent illness and injury. Anytime
All costs
Pediatric services
Children can get pediatric benefits until the end of the calendar year in which they turn 19.
Checkups children get when they're well. Anytime
All costs
Vision care for children: Exam and glasses or contacts. If your eye doctor charges more for a service than our approved amount, you'll pay the difference.
Once a year $0
Ambulatory services Office visit to your primary care doctor Anytime
All costs
Office visit to a specialist
Anytime All costs
Laboratory and diagnostic services

Includes:

  • Lab tests
  • Radiology services like X-rays, EKGs and ultrasounds
Before deductible All costs
After deductible 30%
Imaging services like MRIs Before deductible All costs
After deductible 40% + $200
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 visit while pregnant

  • Tests and ultrasounds you get during the visit are billed under laboratory services
Before deductible
All costs
After deductible 40%
Care you get when you deliver your baby in the hospital Before deductible
All costs
After deductible
40% + $500
Emergency services
Emergency room visit
Before deductible
All costs
After deductible
20% + $250
Transportation by ambulance Before deductible All costs
After deductible 20%
Urgent care center visit
Before deductible
All costs
After deductible 40% + $75
Hospitalization and other services
Care you get when you’re in the hospital for at least one night Before deductible
All costs
After deductible 20% + $500
Hospice care
Anytime All costs
Most other services, like inpatient and outpatient surgery, chemotherapy and sleep studies Before deductible All costs
After 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 40%
Durable medical equipment, like a wheelchair, walker or oxygen tank Before deductible All costs
After deductible 70%
Mental health/substance abuse Care you get at a mental health facility as an inpatient
Before deductible All costs
After deductible 40% + $500
Office visit to an outpatient mental health facility
Before deductible All costs
After deductible $500 + 40%
Care you get at a substance abuse facility as an inpatient or outpatient Anytime All costs