| Company/Plan Name |
 IAC Copay Advantage |
| Deductible |
|
| In-Network |
$5,000 per person, per calendar year |
| Out-Network |
$10,000 per person, per calendar year |
| Maximum Family Deductible |
3 individual deductibles per family, per calendar year |
| Coinsurance |
|
| In-Network |
80/20% to $10,000 (for medical services & supplies) or 80/20% to $20,000 (for inpatient facilities, confinements & surgical services) These accumulate seperately. |
| Out-Network |
50/50% to $10,000 (for medical services & supplies) or 50/50% to $20,000 (for inpatient facilities, confinements & surgical services) These accumulate seperately. |
| Maximum Out-Of-Pocket Coinsurance |
|
| In-Network |
$2,000 for medical services & supplies / $4,000 for inpatient facility confinement & surgical services (accumulate separately) |
| Out-Network |
$5,000 for medical services & supplies/$10,000 for inpatient facilities, confinements & surgical services (accumulates seperately). |
| Maximum Benefit |
$5,000,000 per person medical benefit while insured, $1,000,000 per calendar year. |
| Physician Office Visit |
|
| In-Network |
$35 CoPay
|
| Out-Network |
Deductible & CoInsurance apply.
|
| Outpatient Lab & X-Ray |
|
| In-Network |
Deductible & CoInsurance apply. |
| Out-Network |
Deductible & CoInsurance apply. |
| Outpatient Preventive Care |
|
| In-Network |
Optional (not quoted) |
| Out-Network |
Not available. |
| Prescription Drugs |
Optional (quoted) |
| Generic |
$25 CoPay, then100% paid |
| Brand Name(formulary) |
$100 CoPay, then 100% paid |
| Brand Name(Non-formulary) |
$150 CoPay, then 100% paid |
| Outpatient Surgery |
|
| In-Network |
Deductible & CoInsurance apply. |
| Out-Network |
Deductible & CoInsurance apply. |
| Emergency Room |
|
| In-Network |
After $100 CoPay, Deductible & CoInsurance apply. ($100 CoPay waived if admitted as inpatient.) |
| Out-Network |
After $100 CoPay, Deductible & CoInsurance apply. ($100 CoPay waived if admitted as inpatient.) |
| Maternity Prenatal/Post Natal |
|
| In-Network |
Not covered. |
| Out-Network |
Not covered. |
| Inpatient Benefits |
|
| Hospitalization |
|
| In-Network |
After $250 CoPay, Deductible & CoInsurance apply. |
| Out-Network |
After $250 CoPay, Deductible & CoInsurance apply. |
| Surgical |
|
| In-Network |
Deductible & CoInsurance apply. |
| Out-Network |
Deductible & CoInsurance apply. |
| Maternity |
|
| In-Network |
Not Covered. |
| Out-Network |
Not Covered. |
| Rate Guarantee |
Initial 12 months |
| Optional Benefits |
|
| Supplemental Accident |
$500 or $1000 benefit available (not quoted) |
| 24 Hour Coverage |
Included at no extra premium. |
| Other |
Optional Term Life (quoted) Optional Wellness Benefit (not quoted) Optional Vision Benefit (not quoted) Optional Prescription Drug Benefit (not quoted) Generic $15 CoPay, Brand $100 Deductible then $30 CoPay (formulary) or $45 CoPay (non-formulary) |