| Company/Plan Name |
 InstaCare |
| Deductible |
|
| In-Network |
$1000
|
| Out-Network |
$1000, plus difference between PPO charges & non-PPO charges.
|
| Maximum Family Deductible |
$3,000 per family per year |
| Coinsurance |
|
| In-Network |
80/20% to $5000 |
| Out-Network |
80/20% to $5000 |
| Maximum Out-Of-Pocket Coinsurance |
|
| In-Network |
$1,000 (excluding deductible) |
| Out-Network |
$1,000 (excluding deductible) |
| Maximum Benefit |
$1,000,000 lifetime maximum per person |
| Physician Office Visit |
|
| In-Network |
Deductible & CoInsurance Apply
|
| Out-Network |
Deductible & CoInsurance Apply
|
| Outpatient Lab & X-Ray |
|
| In-Network |
Deductible & CoInsurance Apply |
| Out-Network |
Deductible & CoInsurance Apply |
| Outpatient Preventive Care |
Deductible & CoInsurance Apply |
| In-Network |
Deductible & CoInsurance Apply |
| Out-Network |
Deductible & CoInsurance Apply |
| Prescription Drugs |
|
| Generic |
Deductible & CoInsurance Apply |
| Brand Name(formulary) |
Deductible & CoInsurance Apply |
| Brand Name(Non-formulary) |
Deductible & CoInsurance Apply |
| Outpatient Surgery |
|
| In-Network |
Deductible & CoInsurance Apply |
| Out-Network |
Deductible & CoInsurance Apply |
| Emergency Room |
|
| In-Network |
Deductible & CoInsurance Apply |
| Out-Network |
Deductible & CoInsurance Apply |
| Maternity Prenatal/Post Natal |
|
| In-Network |
Not Covered |
| Out-Network |
Not Covered |
| Inpatient Benefits |
|
| Hospitalization |
|
| In-Network |
Deductible & CoInsurance Apply |
| Out-Network |
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 |
N/A |
| Optional Benefits |
|
| Supplemental Accident |
Not An Available Option |
| 24 Hour Coverage |
Not An Available Option |
| Other |
Not An Available Option |