Copay Select – Benefit Summary
Our Rating: 
| Plan Feature | In-Network |
|---|---|
| Deductible Per individual, per calendar year. Maximum 2 per family) | $1,000 per individual / $2,000 per family $1,500 per individual / $3,000 per family $2,500 per individual / $7,500 per family $5,000 per individual / $15,000 per family $7,500 per individual / $15,000 per family $10,000 per individual / $20,000 per family $12,500 per individual / $25,000 per family |
| Coinsurance Choices The level of coverage provided by the plan after the calendar year Deductible has been satisfied. | You pay 0%, 20%, or 30% |
| Coinsurance Out-of-Pocket Maximum The amount of money an individual pays toward covered hospital and medical expenses during any one calendar year after deductible. | $0, $3,000, $5,000, or $10,000 |
| Lifetime Maximum Benefit | Unlmited |
| Physicians (illness and injury) | |
| Office Visits Primary Care or Specialist | $35 copay (no deductible) |
| Wellness/Preventive Care Benefits From age 16. Covers services associated with both an annual physical exam and an annual gynecological exam. Includes immunizations and routine diagnostic tests received or ordered on the same day as part of the exam when covered services are received in provider’s office. | Covered at 100% |
| Wellness/Preventive Child Care | Covered at 100% |
| Doctor Office Visit Adult, child, in-network only. | $35 copay (no deductible) |
| X-Ray and Lab In conjunction with the preventive office visit, performed in doctor’s office or network facility. | You pay: $0 |
| Child Immunizations Ages 0-18. | You pay: $0 |
| Preventive Mammorgram, Pap Smear, PSA screening | You pay: $0 |
| Outpatient Expense Benefits | |
| X-Ray and Lab Performed in doctor’s office or a network facility. | You pay: 0%, 20%, or 30% coinsurance after deductible |
| Facility/Hospital for Outpatient Surgery | You pay: 0%, 20%, or 30% coinsurance after deductible |
| Surgeon, Assistant Surgeon, and Facility Fees | You pay: 0%, 20%, or 30% coinsurance after deductible |
| Hemodialysis, Radiation, Chemotherapy, Organ Transplant Drugs, and CAT Scans, MRIs | You pay: 0%, 20%, or 30% coinsurance after deductible |
| Emergency Room Fees – Illness | You pay: $100 copay if not admitted, then coinsurance and deductible |
| Emergency Room Fees – Injury | You pay: 0%, 20%, or 30% coinsurance after deductible |
| Spine and Back Disorders CAT scan and MRI tests not subject to this limitation. | You pay: 0%, 20%, or 30% coinsurance after deductible (Limited benefit) |
| Mental and Nervous Disorders Including substance abuse. | You pay: 0%, 20%, or 30% coinsurance after deductible (Limited benefit) |
| Other Outpatient Expenses | You pay: 0%, 20%, or 30% coinsurance after deductible |
| Inpatient Expense Benefits | |
| Room and Board, Intensive Care Unit, Operating Room, Recovery Room, Prescription Drugs, Physician Visit, and Professional Fees of Doctors, Surgeons, and Nurses | You pay: 0%, 20%, or 30% coinsurance after deductible |
| Other Inpatient Services | You pay: 0%, 20%, or 30% coinsurance after deductible |
| Prescription Drug Benefit1 | You Pay |
|---|---|
| Deductible per individual | Separate $500 deductible (does not apply to Tier 1 drugs) |
| Tier 1 | $15 co-payment (no deductible) |
| Tier 2 | $35 co-payment2 |
| Tier 3 | $65 co-payment2 |
| Tier 4 | You pay 25% coinsurance2 |
1 If you purchase a name-brand drug when a generic is available, you pay your generic copay plus the additional cost above the generic price.
2 After paying a combined $500 prescription deductible for drugs in Tiers 2 – 4.
READ YOUR POLICY CAREFULLY; This outline of coverage provides a brief description of the important features of the Policy. This is not the insurance contract, and only the actual Policy provisions will control. The Policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!
