| Company/Plan Name |
 IAC Copay Choice |
| 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 |
| Out-Network |
50/50% to $10,000 |
| Maximum Out-Of-Pocket Coinsurance |
|
| In-Network |
$2,000 (excluding deductible) |
| Out-Network |
$5,000 (excluding deductible) |
| Maximum Benefit |
$5,000,000 per person medical benefit while insured, $1,000,000 per calendar year. |
| Physician Office Visit |
|
| In-Network |
$70 CoPay Applies to office visit charges only. |
| 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 |
$15 CoPay, then 100% paid |
| Brand Name(formulary) |
$30 CoPay, then 50% paid after a $100 calendar year Deductible |
| Brand Name(Non-formulary) |
$45 CoPay, then 50% paid after a $100 calendar year Deductible |
| Outpatient Surgery |
|
| In-Network |
Deductible & Coinsurance apply |
| Out-Network |
Deductible & Coinsurance apply |
| Emergency Room |
|
| In-Network |
$100 CoPay, then Deductible & CoInsurance apply. ($100 CoPay waived if admitted as inpatient.) |
| Out-Network |
$100 CoPay, then 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 |
$250 per confinement CoPay applies, then subject to Deductible & CoInsurance. |
| Out-Network |
$250 per confinement CoPay applies, then subject to Deductible & CoInsurance. |
| Surgical |
|
| In-Network |
Deductible & Coinsurance apply |
| Out-Network |
Deductible & Coinsurance apply |
| Maternity |
|
| In-Network |
Not Covered. |
| Out-Network |
Not Covered. |
| Rate Guarantee |
|
| 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 $25 CoPay, Brand Formulary $30 CoPay or Brand Non-Formulary $45 CoPay |