Skip to main content

Benefits Comparison Tool

The Benefits Comparison Tool provides a side-by-side comparison of the medical and dental plans offered by Princeton University, including premium amounts and covered services. This is only an estimation of benefits; for more details about covered services, refer to the Summary Plan Descriptions.

Select plan type you want compare:
2019 Consumer Directed Health Plan
2019 Health Maintenance Organization (HMO) Plan
2019 J-1 Visa Plan
2019 Princeton Health Plan
2020 Consumer Directed Health Plan
2020 Health Maintenance Organization (HMO) Plan
2020 J-1 Visa Plan
2020 Princeton Health Plan
2019 Basic Option PPO Plan
2019 DMO Plan
2019 High Option PPO Plan
2020 Basic Option PPO Plan
2020 DMO Plan
2020 High Option PPO Plan
2019 Vision Plan
2020 Vision Plan

Annual Deductibles

In-Network
Individual: None
Family: None
Out-of-Network
Individual: $50
Family: $150
In-Network
Individual: $1,500.00
Family: $3,000.00
Out-of-Network
Individual: $3,000.00
Family: $6,000.00
In-Network
Individual: $0.00
Family: $0.00
In-Network
Individual: $0
Family: $0
In- or Out-of-Network
Individual: $50.00 (basic and major services)
Family: $150.00 (basic and major services)
In- or Out-of-Network
Individual: $500.00
Family: $1,000.00
In-Network
Individual: $200.00
Family: $400.00
Out-of-Network
Individual: $750.00
Family: $1,500.00
In-Network
Individual: None
Family: None
Out-of-Network
Individual: $50
Family: $150
In-Network
Individual: $1,500.00
Family: $3,000.00
Out-of-Network
Individual: $3,000.00
Family: $6,000.00
In-Network
Individual: $0.00
Family: $0.00
In-Network
Individual: $0
Family: $0
In- or Out-of-Network
Individual: $50.00 (basic and major services)
Family: $150.00 (basic and major services)
In- or Out-of-Network
Individual: $500.00
Family: $1,000.00
In-Network
Individual: $200.00
Family: $400.00
Out-of-Network
Individual: $750.00
Family: $1,500.00

Employee Monthly Contributions

Employee: $20.69
Employee & Child: $48.16
Family: $72.62
Employee & Spouse: $44.19
Employee: $20.00
Employee & Child: $60.00
Family: $120.00
Employee & Spouse: $80.00
Employee: $25.15
Employee & Child: $49.05
Family: $70.09
Employee & Spouse: $50.72
Less than $75,000
Employee: $73.00
Employee & Child: $212.00
Family: $437.00
Employee & Spouse: $284.00
$75,001–150,000
Employee: $74.00
Employee & Child: $218.00
Family: $448.00
Employee & Spouse: $293.00
$150,001 and over
Employee: $78.00
Employee & Child: $227.00
Family: $467.00
Employee & Spouse: $305.00
Employee: $67.79
Employee & Child: $132.84
Family: $188.96
Employee & Spouse: $136.80
Employee: $0.00
Employee & Child: $260.00
Family: $526.00
Employee & Spouse: $345.00
Employee: $117.00
Employee & Child: $323.00
Family: $608.00
Employee & Spouse: $410.00
Employee: $15.16
Employee & Child: $24.83
Family: $40.04
Employee & Spouse: $24.38
Employee: $20.69
Employee & Child: $48.16
Family: $72.62
Employee & Spouse: $44.19
Employee: $20.00
Employee & Child: $60.00
Family: $120.00
Employee & Spouse: $80.00
Employee: $25.15
Employee & Child: $49.05
Family: $70.09
Employee & Spouse: $50.72
Less than $75,000
Employee: $74.00
Employee & Child: $216.00
Family: $446.00
Employee & Spouse: $290.00
$75,001–150,000
Employee: $77.00
Employee & Child: $226.00
Family: $464.00
Employee & Spouse: $303.00
$150,001 and over
Employee: $81.00
Employee & Child: $235.00
Family: $483.00
Employee & Spouse: $316.00
Employee: $67.79
Employee & Child: $132.84
Family: $188.96
Employee & Spouse: $136.80
Employee: $0.00
Employee & Child: $269.00
Family: $544.00
Employee & Spouse: $357.00
Employee: $121.00
Employee & Child: $334.00
Family: $629.00
Employee & Spouse: $424.00
Employee: $15.16
Employee & Child: $24.83
Family: $40.04
Employee & Spouse: $24.38

Out-of-Pocket Maximum (OPM)

In- or Out-of-Network
Individual: $2,000.00
Family:
In-Network
Individual: $3,000.00
Family: $6,000.00
Out-of-Network
Individual: $6,000.00
Family: $12,000.00
In-Network
Individual: None
Family:
In-Network
Individual: $2,500.00
Family: $5,000.00
In-Network
Individual: $2,000.00
Family:
Out-of-Network
Individual: $1,500.00
Family:
In- or Out-of-Network
Individual: $2,500.00
Family: $5,000.00
Less than $75,000
In-Network
Individual: $1,550
Family: $3,100
$75,001–150,000
In-Network
Individual: $2,350
Family: $4,700
$150,001 and over
In-Network
Individual: $3,100
Family: $6,200
Less than $75,000
Out-of-Network
Individual: $4,500
Family: $9,000
$75,001–150,000
Out-of-Network
Individual: $4,700
Family: $9,400
$150,001 and over
Out-of-Network
Individual: $6,200
Family: $12,400
In- or Out-of-Network
Individual: $2,000.00
Family:
In-Network
Individual: $3,000.00
Family: $6,000.00
Out-of-Network
Individual: $6,000.00
Family: $12,000.00
In-Network
Individual: None
Family:
In-Network
Individual: $2,500.00
Family: $5,000.00
In-Network
Individual: $2,000.00
Family:
Out-of-Network
Individual: $1,500.00
Family:
In- or Out-of-Network
Individual: $2,500.00
Family: $5,000.00
Less than $75,000
In-Network
Individual: $1,550
Family: $3,100
$75,001–150,000
In-Network
Individual: $2,350
Family: $4,700
$150,001 and over
In-Network
Individual: $3,100
Family: $6,200
Less than $75,000
Out-of-Network
Individual: $4,500
Family: $9,000
$75,001–150,000
Out-of-Network
Individual: $4,700
Family: $9,400
$150,001 and over
Out-of-Network
Individual: $6,200
Family: $12,400

Services

Exam (Once every calendar year)

Comprehensive Vision Exam

In-Network
$10 copayment
Out-of-Network
100% with reimbursement up to $45
In-Network
$10 copayment
Out-of-Network
100% with reimbursement up to $45

Prescription Lenses (Once every calendar year)

Single Vision

In-Network
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $30
In-Network
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $30

Lined Bifocals

In-Network
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $50
In-Network
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $50

Progressives

In-Network
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $50
In-Network
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $50

Lined Trifocals

In-Network
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $65
In-Network
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $65

Lenticular

In-Network
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $100
In-Network
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $100

Frames (Once every calendar year)

All

In-Network
100% with coverage up to $155 after a $10 copayment / 100% with coverage up to $85 after a $10 copayment at Costco, Walmart, or Sam's Club / If purchasing lenses and frames together, on $10 copayment applies
Out-of-Network
100% with reimbursement up to $70
In-Network
100% with coverage up to $155 after a $10 copayment / 100% with coverage up to $85 after a $10 copayment at Costco, Walmart, or Sam's Club / If purchasing lenses and frames together, on $10 copayment applies
Out-of-Network
100% with reimbursement up to $70

Prescription Contact Lenses (Once every calendar year)

Evaluation Fees

In-Network
Copayment not to exceed $60
Out-of-Network
Not covered
In-Network
Copayment not to exceed $60
Out-of-Network
Not covered

Fitting Costs

In-Network
Copayment not to exceed $60
Out-of-Network
Not covered
In-Network
Copayment not to exceed $60
Out-of-Network
Not covered

Materials

In- or Out-of-Network
100% reimbursement up to $140
In- or Out-of-Network
100% reimbursement up to $140

Preventive & Diagnostic Services

Examinations & Visits

In- or Out-of-Network
Reimbursement based on 100% of in-network charge
In-Network
$0
In-Network
$0
Out-of-Network
$0
In- or Out-of-Network
Reimbursement based on 100% of in-network charge
In-Network
$0
In-Network
$0
Out-of-Network
$0

X-Ray Services

In- or Out-of-Network
Reimbursement based on 100% of in-network charge
In-Network
$0
In-Network
$0
Out-of-Network
$0
In- or Out-of-Network
Reimbursement based on 100% of in-network charge
In-Network
$0
In-Network
$0
Out-of-Network
$0

Cleanings

In- or Out-of-Network
Reimbursement based on 100% of in-network charge
In-Network
$0
In-Network
$0
Out-of-Network
$0
In- or Out-of-Network
Reimbursement based on 100% of in-network charge
In-Network
$0
In-Network
$0
Out-of-Network
$0

Flouride Treatments

In- or Out-of-Network
Reimbursement based on 100% of in-network charge
In-Network
$0
In-Network
$0
Out-of-Network
$0
In- or Out-of-Network
Reimbursement based on 100% of in-network charge
In-Network
$0
In-Network
$0
Out-of-Network
$0

Basic Services

Amalgam (Silver) Fillings

In- or Out-of-Network
Reimbursement based on 50% of in-network charge
In-Network
$0
In-Network
20%
Out-of-Network
30%
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
In-Network
$0
In-Network
20%
Out-of-Network
30%

Root Canal Therapy (Anterior Teeth)

In- or Out-of-Network
Reimbursement based on 50% of in-network charge
In-Network
$0
In-Network
20%
Out-of-Network
30%
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
In-Network
$0
In-Network
20%
Out-of-Network
30%

Root Canal Therapy (Molars)

In- or Out-of-Network
Reimbursement based on 50% of in-network charge
In-Network
20%
Out-of-Network
30%
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
In-Network
20%
Out-of-Network
30%

Composite Fillings (Anterior Teeth)

In- or Out-of-Network
Reimbursement based on 50% of in-network charge
In-Network
$0
In-Network
20%
Out-of-Network
30%
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
In-Network
$0
In-Network
20%
Out-of-Network
30%

Stainless Steel Crowns

In- or Out-of-Network
Reimbursement based on 50% of in-network charge
In-Network
$0
In-Network
20%
Out-of-Network
30%
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
In-Network
$0
In-Network
20%
Out-of-Network
30%

Uncomplicated Extractions

In- or Out-of-Network
Reimbursement based on 50% of in-network charge
In-Network
$0
In-Network
20%
Out-of-Network
30%
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
In-Network
$0
In-Network
20%
Out-of-Network
30%

Major Services

High Noble Metal & Porcelain Inlays

In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
In-Network
40%
In-Network
40%
Out-of-Network
50%
In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
In-Network
40%
In-Network
40%
Out-of-Network
50%

High Noble Metal Restorations

In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
In-Network
40%
In-Network
40%
Out-of-Network
50%
In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
In-Network
40%
In-Network
40%
Out-of-Network
50%

Crowns

In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
In-Network
40%
In-Network
40%
Out-of-Network
50%
In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
In-Network
40%
In-Network
40%
Out-of-Network
50%

Root Canal Therapy (Molars)

In-Network
40%
In-Network
40%

Implants

In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
In-Network
40%
In-Network
40%
Out-of-Network
50%
In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
In-Network
40%
In-Network
40%
Out-of-Network
50%

Orthodontia

Orthodontics

In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
In-Network
50% / No lifetime maximum / Covers children and adults
In-Network
50% / Lifetime maximum benefit of $2,000 / Covers children and adults
Out-of-Network
50% / Lifetime maximum benefit of $1,500 / Covers children and adults
In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
In-Network
50% / No lifetime maximum / Covers children and adults
In-Network
50% / Lifetime maximum benefit of $2,000 / Covers children and adults
Out-of-Network
50% / Lifetime maximum benefit of $1,500 / Covers children and adults

Basis of Reimbursement

Reimbursement

In- or Out-of-Network
Maximum allowable charge
In-Network
Negotiated fee
In-Network
Negotiated fee
Out-of-Network
80th percentile of reasonable and customary charges
In- or Out-of-Network
Maximum allowable charge
In-Network
Negotiated fee
In-Network
Negotiated fee
Out-of-Network
80th percentile of reasonable and customary charges

Physician Visits

Telemedicine (Offered through Teladoc)

In-Network
$40 until deductible is met, then 20% after deductible
Out-of-Network
NA
In-Network
$0
In- or Out-of-Network
$40 until deductible is met, then 20% after deductible
In-Network
$0
Out-of-Network
NA
In-Network
$40 until deductible is met, then 20% after deductible
Out-of-Network
NA
In-Network
$0
In- or Out-of-Network
$40 until deductible is met, then 20% after deductible
In-Network
$0
Out-of-Network
NA

Telemental Health (Offered through Teladoc)

In-Network
20% after deductible
Out-of-Network
NA
In-Network
$25 copayment
In- or Out-of-Network
20% after deductible
In-Network
$30 copayment
Out-of-Network
NA
In-Network
20% after deductible
Out-of-Network
NA
In-Network
$25 copayment
In- or Out-of-Network
20% after deductible
In-Network
$30 copayment
Out-of-Network
NA

Primary Care Physician (PCP)

In-Network
20% after deductible
Out-of-Network
50% after deductible
In-Network
$20 copayment
In- or Out-of-Network
20% after deductible
In-Network
$20 copayment
Out-of-Network
40% after deductible
In-Network
20% after deductible
Out-of-Network
50% after deductible
In-Network
$20 copayment
In- or Out-of-Network
20% after deductible
In-Network
$20 copayment
Out-of-Network
40% after deductible

Preventive Care & Immunizations

In-Network
$0
Out-of-Network
50% after deductible
In-Network
$0
In- or Out-of-Network
20% after deductible
In-Network
$0
Out-of-Network
40% after deductible
In-Network
$0
Out-of-Network
50% after deductible
In-Network
$0
In- or Out-of-Network
20% after deductible
In-Network
$0
Out-of-Network
40% after deductible

Specialists

In-Network
$25 copayment
In- or Out-of-Network
20% after deductible
In-Network
$25 copayment
In- or Out-of-Network
20% after deductible

Emergency & Urgent Care Services

Urgent Care Center

In-Network
$0 after deductible
Out-of-Network
50% after deductible
In-Network
$25 copayment
In- or Out-of-Network
20% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
In-Network
$0 after deductible
Out-of-Network
50% after deductible
In-Network
$25 copayment
In- or Out-of-Network
20% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible

Emergency Room (No coverage for non-emergencies)

In- or Out-of-Network
$0 after deductible
In-Network
$175 copayment (waived if admitted)
In- or Out-of-Network
20% after deductible
In- or Out-of-Network
$175 copayment (waived if admitted)
In- or Out-of-Network
$0 after deductible
In-Network
$175 copayment (waived if admitted)
In- or Out-of-Network
20% after deductible
In- or Out-of-Network
$175 copayment (waived if admitted)

Inpatient Services

Medical & Surgical Procedures

In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
In-Network
$175 copayment
In- or Out-of-Network
20% after deductible
In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
40% after deductible
In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
In-Network
$175 copayment
In- or Out-of-Network
20% after deductible
In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
40% after deductible

Mental Health

In-Network
20% after deductible
Out-of-Network
50% after deductible
In-Network
$175 copayment
In- or Out-of-Network
20% after deductible
In-Network
10% after deductible
Out-of-Network
40% after deductible
In-Network
20% after deductible
Out-of-Network
50% after deductible
In-Network
$175 copayment
In- or Out-of-Network
20% after deductible
In-Network
10% after deductible
Out-of-Network
40% after deductible

Outpatient Services

Surgical Procedures

In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
In-Network
$0 (Independent Facility) / $75 copayment (Hospital)
In- or Out-of-Network
20% after deductible
In-Network (Preferred)
10% after deductable
In-Network (Non-Preferred)
20% after deductable
Out-of-Network
40% after deductable
In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
In-Network
$0 (Independent Facility) / $75 copayment (Hospital)
In- or Out-of-Network
20% after deductible
In-Network (Preferred)
10% after deductable
In-Network (Non-Preferred)
20% after deductable
Out-of-Network
40% after deductable

Laboratory

In-Network (Preferred)
$0 after deductible
In-Network (Non-Preferred)
40% after deductible
Out-of-Network
Not covered
In-Network
$0
In- or Out-of-Network
20% after deductible
In-Network (Preferred)
$0
In-Network (Non-Preferred)
40%
Out-of-Network
Not covered
In-Network (Preferred)
$0 after deductible
In-Network (Non-Preferred)
40% after deductible
Out-of-Network
Not covered
In-Network
$0
In- or Out-of-Network
20% after deductible
In-Network (Preferred)
$0
In-Network (Non-Preferred)
40%
Out-of-Network
Not covered

Radiology (X-Ray)

In-Network
$0 after deductible (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
In-Network
$0 (Independent Facility) / $50 copayment (Hospital)
In- or Out-of-Network
20% after deductible
In-Network
$0 (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
In-Network
$0 after deductible (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
In-Network
$0 (Independent Facility) / $50 copayment (Hospital)
In- or Out-of-Network
20% after deductible
In-Network
$0 (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered

Hi-Tech Radiology (MRI, CAT, etc.)

In-Network
$0 after deductible (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
In-Network
$0 (Independent Facility) / $100 copayment (Hospital)
In- or Out-of-Network
20% after deductible
In-Network (Preferred)
$0 (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
In-Network
$0 after deductible (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
In-Network
$0 (Independent Facility) / $100 copayment (Hospital)
In- or Out-of-Network
20% after deductible
In-Network (Preferred)
$0 (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered

Mental Health

In-Network
20% after deductible
Out-of-Network
25% after deductible
In-Network
$25 copayment
In- or Out-of-Network
20% after deductible
In-Network
$30 copayment
Out-of-Network
25% no deductible
In-Network
20% after deductible
Out-of-Network
25% after deductible
In-Network
$25 copayment
In- or Out-of-Network
20% after deductible
In-Network
$30 copayment
Out-of-Network
25% no deductible

Annual Eye Exam

In- or Out-of-Network
Not covered
In-Network
$25 copayment
In- or Out-of-Network
Not covered
In- or Out-of-Network
Not covered
In- or Out-of-Network
Not covered
In-Network
$25 copayment
In- or Out-of-Network
Not covered
In- or Out-of-Network
Not covered

Prescription Eyeglasses and/or Contact Lenses

In- or Out-of-Network
Not covered
In-Network
$70 reimbursement every 2 years
In- or Out-of-Network
Not covered
In- or Out-of-Network
Not covered
In- or Out-of-Network
Not covered
In-Network
$70 reimbursement every 2 years
In- or Out-of-Network
Not covered
In- or Out-of-Network
Not covered

Physical Therapy (100 visits per calendar year)

In-Network
20% after deductible
Out-of-Network
50% after deductible
In-Network
$15 copayment
In- or Out-of-Network
20% after deductible
In-Network
10% after deductible
Out-of-Network
50% after deductible
In-Network
20% after deductible
Out-of-Network
50% after deductible
In-Network
$15 copayment
In- or Out-of-Network
20% after deductible
In-Network
10% after deductible
Out-of-Network
50% after deductible

Speech Therapy / Occupational Therapy / Pulmonary & Cardiac Rehabilitation (100 visits per calendar year)

In-Network
20% after deductible
Out-of-Network
50% after deductible
In-Network
$25 copayment
In- or Out-of-Network
20% after deductible
In-Network
10% after deductible
Out-of-Network
40% after deductible
In-Network
20% after deductible
Out-of-Network
50% after deductible
In-Network
$25 copayment
In- or Out-of-Network
20% after deductible
In-Network
10% after deductible
Out-of-Network
40% after deductible

Chiropractic Care (20 visits per calendar year)

In-Network
20% after deductible
Out-of-Network
50% after deductible
In-Network
$25 copayment
In- or Out-of-Network
20% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
In-Network
20% after deductible
Out-of-Network
50% after deductible
In-Network
$25 copayment
In- or Out-of-Network
20% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible

Acupuncture (20 visits per calendar year)

In-Network
20% after deductible
Out-of-Network
50% after deductible
In-Network
$25 copayment
In- or Out-of-Network
20% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
In-Network
20% after deductible
Out-of-Network
50% after deductible
In-Network
$25 copayment
In- or Out-of-Network
20% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible

Maternity

Prenatal Care Visits

In-Network (Preferred)
10% after deductible for the first visit, $0 for subsequent visits
In-Network (Non-Preferred)
20% after deductible for the first visit, $0 for subsequent visits
Out-of-Network
50% after deductible
In-Network
$25 copayment for first visit, $0 for subsequent visits
In- or Out-of-Network
20% after deductible
In-Network (Preferred)
$30 copayment for the first visit, $0 for subsequent visits
In-Network (Non-Preferred)
$60 copayment for the first visit, $0 for subsequent visits
Out-of-Network
40% after deductible
In-Network (Preferred)
10% after deductible for the first visit, $0 for subsequent visits
In-Network (Non-Preferred)
20% after deductible for the first visit, $0 for subsequent visits
Out-of-Network
50% after deductible
In-Network
$25 copayment for first visit, $0 for subsequent visits
In- or Out-of-Network
20% after deductible
In-Network (Preferred)
$30 copayment for the first visit, $0 for subsequent visits
In-Network (Non-Preferred)
$60 copayment for the first visit, $0 for subsequent visits
Out-of-Network
40% after deductible

Delivery

In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
In-Network
$175 copayment
In- or Out-of-Network
20% after deductible
In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
40% after deductible
In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
In-Network
$175 copayment
In- or Out-of-Network
20% after deductible
In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
40% after deductible

Post-Partum Visits

In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
In-Network
$25 copayment
In- or Out-of-Network
20% after deductible
In-Network (Preferred)
$30 copayment
In-Network (Non-Preferred)
$60 copayment
Out-of-Network
40% after deductible
In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
In-Network
$25 copayment
In- or Out-of-Network
20% after deductible
In-Network (Preferred)
$30 copayment
In-Network (Non-Preferred)
$60 copayment
Out-of-Network
40% after deductible