| Company/Plan Name |
 Options Blue (Family) |
| Deductible |
|
| In-Network |
$5,250
|
| Out-Network |
$5,250
|
| Maximum Family Deductible |
1 Per Family, Per Year |
| Coinsurance |
|
| In-Network |
80/20% |
| Out-Network |
80/20% |
| Maximum Out-Of-Pocket Coinsurance |
|
| In-Network |
$5,250 (excluding Deductible) |
| Out-Network |
$5,250 (excluding deductible) plus difference between PPO charges & non-PPO charges |
| Maximum Benefit |
$5,000,000 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 |
|
| In-Network |
Option 1: 100% to a maximum of $300, then 80% after Deductible (not quoted); Option 2: 80% after Deductible (quoted) |
| Out-Network |
Option 1: 100% to a maximum of $300, then 80% after Deductible (not quoted); Option 2: 80% after Deductible (quoted) |
| 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 |
Prenatal - 100% (deductible does not apply). Delivery & Post-natal care - For the first 18 months of coverage: Benefits are limited to $500 , which counts towards your deduct & coins. Beginning with 19th month of coverage, 80% after Deductible |
| Out-Network |
Prenatal - 100% (deductible does not apply). Delivery & Post-natal care - For the first 18 months of coverage: Benefits are limited to $500 , which counts towards your deduct & coins. Beginning with 19th month of coverage, 80% after Deductible |
| 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 |
Delivery & Post-natal care - Benefits are limited to $500 (goes toward your deduct for the 1st 18 months of coverage). Beginning the 19th month of coverage, 80% after Deductible |
| Out-Network |
Delivery & Post-natal care - Benefits are limited to $500 (goes toward your deduct for the 1st 18 months of coverage). Beginning the 19th month of coverage, 80% after Deductible |
| Rate Guarantee |
No rate guarantee available |
| Optional Benefits |
|
| Supplemental Accident |
Not An Available Option |
| 24 Hour Coverage |
Not An Available Option |
| Other |
Not An Available Option |