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:
2024 Aetna Princeton Health Plan
2024 Consumer Directed Health Plan
2024 Health Maintenance Organization (HMO) Plan
2024 J-1 Visa Plan
2024 Princeton Medicare Plan
2024 Retiree Aetna Consumer Directed Health Plan
2024 Retiree Aetna Princeton Health Plan
2024 Retiree Health Maintenance Organization (HMO) Plan
2024 Retiree UnitedHealthcare Princeton Health Plan
2024 UnitedHealthcare Princeton Health Plan
2025 Aetna Exclusive Provider Organization (EPO) Plan
2025 Aetna Point of Service (POS) Plan
2025 Consumer Directed Health Plan
2025 J-1 Visa Plan
2025 Princeton Medicare Plan
2025 Retiree Aetna Consumer Directed Health Plan
2025 Retiree Aetna Exclusive Provider Organization (EPO) Plan
2025 Retiree Aetna Point of Service Plan (POS)
2025 Retiree United Healthcare Point of Service Plan
2025 UnitedHealthcare Point of Service (POS) Plan
2024 Basic Option PPO Plan
2024 DMO Plan
2024 High Option PPO Plan
2025 Basic Option PPO Plan
2025 DMO Plan
2025 High Option PPO Plan
2024 Vision Plan
2025 Vision Plan
Annual Deductibles
In-Network
Individual: $250.00
Family: $500.00
Individual: $250.00
Family: $500.00
Out-of-Network
Individual: $1,000.00
Family: $2,000.00
Individual: $1,000.00
Family: $2,000.00
In-Network
Individual: None
Family: None
Individual: None
Family: None
Out-of-Network
Individual: $50
Family: $150
Individual: $50
Family: $150
In-Network
Individual: $1,600.00
Family: $3,200.00
Individual: $1,600.00
Family: $3,200.00
Out-of-Network
Individual: $3,200.00
Family: $6,400.00
Individual: $3,200.00
Family: $6,400.00
In-Network
Individual: $0.00
Family: $0.00
Individual: $0.00
Family: $0.00
In-Network
Individual: $0
Family: $0
Individual: $0
Family: $0
In- or Out-of-Network
Individual: $50.00 (basic and major services)
Family: $150.00 (basic and major services)
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
Individual: $500.00
Family: $1,000.00
—
In-Network
Individual: $1,600.00
Family: $3,200.00
Individual: $1,600.00
Family: $3,200.00
Out-of-Network
Individual: $3,200.00
Family: $6,400.00
Individual: $3,200.00
Family: $6,400.00
In-Network
Individual: $250.00
Family: $500.00
Individual: $250.00
Family: $500.00
Out-of-Network
Individual: $1,000.00
Family: $2,000.00
Individual: $1,000.00
Family: $2,000.00
In-Network
Individual: $0
Family: $0
Individual: $0
Family: $0
In-Network
Individual: $250.00
Family: $500.00
Individual: $250.00
Family: $500.00
Out-of-Network
Individual: $1,000.00
Family: $2,000.00
Individual: $1,000.00
Family: $2,000.00
In-Network
Individual: $250.00
Family: $500.00
Individual: $250.00
Family: $500.00
Out-of-Network
Individual: $1,000.00
Family: $2,000.00
Individual: $1,000.00
Family: $2,000.00
—
In-Network (Tier 1)
Individual: $0
Family: $0
Individual: $0
Family: $0
In-Network (Tier 2)
Individual: $200
Family: $400
Individual: $200
Family: $400
In-Network (Tier 1)
Individual: $100
Family: $200
Individual: $100
Family: $200
In-Network (Tier 2)
Individual: $500
Family: $1,000
Individual: $500
Family: $1,000
Out-of-Network
Individual: $1,500
Family: $3,000
Individual: $1,500
Family: $3,000
In-Network
Individual: None
Family: None
Individual: None
Family: None
Out-of-Network
Individual: $50
Family: $150
Individual: $50
Family: $150
In-Network (Tier 1)
Individual: $1,650
Family: $3,300
Individual: $1,650
Family: $3,300
In-Network (Tier 2)
Individual: $2,450
Family: $4,900
Individual: $2,450
Family: $4,900
Out-of-Network
Individual: $3,200
Family: $6,400
Individual: $3,200
Family: $6,400
In-Network
Individual: $0.00
Family: $0.00
Individual: $0.00
Family: $0.00
In- or Out-of-Network
Individual: $50.00 (basic and major services)
Family: $150.00 (basic and major services)
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
Individual: $500.00
Family: $1,000.00
—
In-Network (Tier 1)
Individual: $1,650
Family: $3,300
Individual: $1,650
Family: $3,300
In-Network (Tier 2)
Individual: $2,450
Family: $4,900
Individual: $2,450
Family: $4,900
Out-of-Network
Individual: $3,200
Family: $6,400
Individual: $3,200
Family: $6,400
In-Network (Tier 1)
Individual: $0
Family: $0
Individual: $0
Family: $0
In-Network (Tier 2)
Individual: $200
Family: $400
Individual: $200
Family: $400
In-Network (Tier 1)
Individual: $100
Family: $200
Individual: $100
Family: $200
In-Network (Tier 2)
Individual: $500
Family: $1,000
Individual: $500
Family: $1,000
Out-of-Network
Individual: $1,500.00
Family: $3,000.00
Individual: $1,500.00
Family: $3,000.00
In-Network
Individual: $300.00
Family: $600.00
Individual: $300.00
Family: $600.00
Out-of-Network
Individual: $1,500.00
Family: $3,000.00
Individual: $1,500.00
Family: $3,000.00
In-Network
Individual: $300
Family: $600
Individual: $300
Family: $600
Out-of-Network
Individual: $1,500
Family: $3,000
Individual: $1,500
Family: $3,000
—
Employee Monthly Contributions
Employee:
$135.00
Employee & Child: $377.00
Family: $709.00
Employee & Spouse: $479.00
Employee & Child: $377.00
Family: $709.00
Employee & Spouse: $479.00
Employee:
$6.00
Employee & Child: $19.00
Family: $33.00
Employee & Spouse: $15.00
Employee & Child: $19.00
Family: $33.00
Employee & Spouse: $15.00
Employee:
$21.00 (Employer funded HSA $200 per calendar year.)
Employee & Child: $63.00 (Employer funded HSA $400 per calendar year.)
Family: $127.00 (Employer funded HSA $400 per calendar year.)
Employee & Spouse: $85.00 (Employer funded HSA $400 per calendar year.)
Employee & Child: $63.00 (Employer funded HSA $400 per calendar year.)
Family: $127.00 (Employer funded HSA $400 per calendar year.)
Employee & Spouse: $85.00 (Employer funded HSA $400 per calendar year.)
Employee:
$9.00
Employee & Child: $17.00
Family: $26.00
Employee & Spouse: $19.00
Employee & Child: $17.00
Family: $26.00
Employee & Spouse: $19.00
Less than $55,000
Employee:
$68.00 Employee & Child: $207.00
Family: $378.00
Employee & Spouse: $277.00
$55,001–$75,000
Employee:
$73.00 Employee & Child: $223.00
Family: $402.00
Employee & Spouse: $286.00
$75,001–$100,000
Employee:
$78.00 Employee & Child: $235.00
Family: $449.00
Employee & Spouse: $305.00
$100,001–$150,000
Employee:
$86.00 Employee & Child: $254.00
Family: $521.00
Employee & Spouse: $340.00
$150,001 and over
Employee:
$91.00 Employee & Child: $265.00
Family: $544.00
Employee & Spouse: $355.00
Employee:
$51.00
Employee & Child: $99.00
Family: $142.00
Employee & Spouse: $103.00
Employee & Child: $99.00
Family: $142.00
Employee & Spouse: $103.00
Employee:
$0.00
Employee & Child: $302.00
Family: $612.00
Employee & Spouse: $402.00
Employee & Child: $302.00
Family: $612.00
Employee & Spouse: $402.00
—
—
—
—
—
Employee:
$135.00
Employee & Child: $377.00
Family: $709.00
Employee & Spouse: $479.00
Employee & Child: $377.00
Family: $709.00
Employee & Spouse: $479.00
Employee:
$15.54
Employee & Child: $25.46
Family: $41.05
Employee & Spouse: $25.00
Employee & Child: $25.46
Family: $41.05
Employee & Spouse: $25.00
Less than $55,000
Employee:
$68.00 Employee & Child: $207.00
Family: $340.00
Employee & Spouse: $277.00
$55,001–$75,000
Employee:
$73.00 Employee & Child: $223.00
Family: $380.00
Employee & Spouse: $286.00
$75,001–$100,000
Employee:
$78.00 Employee & Child: $235.00
Family: $429.00
Employee & Spouse: $305.00
$100,001–$150,000
Employee:
$86.00 Employee & Child: $254.00
Family: $473.00
Employee & Spouse: $340.00
$150,001 and over
Employee:
$91.00 Employee & Child: $265.00
Family: $501.00
Employee & Spouse: $355.00
Employee:
$135.00
Employee & Child: $377.00
Family: $709.00
Employee & Spouse: $479.00
Employee & Child: $377.00
Family: $709.00
Employee & Spouse: $479.00
Employee:
$7.33
Employee & Child: $21.96
Family: $36.37
Employee & Spouse: $17.68
Employee & Child: $21.96
Family: $36.37
Employee & Spouse: $17.68
Employee:
$22.00 (Employer funded HSA $500 per calendar year.)
Employee & Child: $66.00 (Employer funded HSA $1,000 per calendar year.)
Family: $121.00 (Employer funded HSA $1,000 per calendar year.)
Employee & Spouse: $89.00 (Employer funded HSA $1,000 per calendar year.)
Employee & Child: $66.00 (Employer funded HSA $1,000 per calendar year.)
Family: $121.00 (Employer funded HSA $1,000 per calendar year.)
Employee & Spouse: $89.00 (Employer funded HSA $1,000 per calendar year.)
Employee:
$9.00
Employee & Child: $17.00
Family: $26.00
Employee & Spouse: $19.00
Employee & Child: $17.00
Family: $26.00
Employee & Spouse: $19.00
Employee:
$54.33
Employee & Child: $105.87
Family: $151.27
Employee & Spouse: $109.91
Employee & Child: $105.87
Family: $151.27
Employee & Spouse: $109.91
Employee:
$0.00
Employee & Child: $329.00
Family: $667.00
Employee & Spouse: $438.00
Employee & Child: $329.00
Family: $667.00
Employee & Spouse: $438.00
—
—
—
—
—
Employee:
$147.00
Employee & Child: $411.00
Family: $773.00
Employee & Spouse: $522.00
Employee & Child: $411.00
Family: $773.00
Employee & Spouse: $522.00
Employee:
$15.54
Employee & Child: $25.46
Family: $41.05
Employee & Spouse: $25.00
Employee & Child: $25.46
Family: $41.05
Employee & Spouse: $25.00
Out-of-Pocket Maximum (OPM)
In-Network
Individual: $2,750
Family: $5,500
Individual: $2,750
Family: $5,500
Out-of-Network
Individual: $5,500
Family: $11,000
Individual: $5,500
Family: $11,000
In- or Out-of-Network
Individual: $2,000.00
Family:
Individual: $2,000.00
Family:
In-Network
Individual: $3,200.00
Family: $6,400.00
Individual: $3,200.00
Family: $6,400.00
Out-of-Network
Individual: $6,400.00
Family: $12,800.00
Individual: $6,400.00
Family: $12,800.00
In-Network
Individual: None
Family:
Individual: None
Family:
In-Network
Individual: $1,500.00
Family: $3,000.00
Individual: $1,500.00
Family: $3,000.00
In-Network
Individual: $2,000.00
Family:
Individual: $2,000.00
Family:
Out-of-Network
Individual: $1,500.00
Family:
Individual: $1,500.00
Family:
In- or Out-of-Network
Individual: $2,500.00
Family: $5,000.00
Individual: $2,500.00
Family: $5,000.00
—
In-Network
Individual: $3,000.00
Family: $6,000.00
Individual: $3,000.00
Family: $6,000.00
Out-of-Network
Individual: $6,000.00
Family: $12,000.00
Individual: $6,000.00
Family: $12,000.00
In-Network
Individual: $2,750
Family: $5,500
Individual: $2,750
Family: $5,500
In-Network
Individual: $5,500
Family: $11,000
Individual: $5,500
Family: $11,000
In-Network
Individual: $1,500.00
Family: $3,000.00
Individual: $1,500.00
Family: $3,000.00
In-Network
Individual: $2,750
Family: $5,500
Individual: $2,750
Family: $5,500
Out-of-Network
Individual: $5,500
Family: $11,000
Individual: $5,500
Family: $11,000
In-Network
Individual: $2,750
Family: $5,500
Individual: $2,750
Family: $5,500
Out-of-Network
Individual: $5,500
Family: $11,000
Individual: $5,500
Family: $11,000
—
In-Network (Tier 1)
Individual: $1,500
Family: $3,000
Individual: $1,500
Family: $3,000
In-Network (Tier 2)
Individual: $2,000
Family: $4,000
Individual: $2,000
Family: $4,000
In-Network (Tier 1)
Individual: $2,500
Family: $5,000
Individual: $2,500
Family: $5,000
In-Network (Tier 2)
Individual: $3,200
Family: $6,400
Individual: $3,200
Family: $6,400
Out-of-Network
Individual: $6,000
Family: $12,000
Individual: $6,000
Family: $12,000
In- or Out-of-Network
Individual: $2,000.00
Family:
Individual: $2,000.00
Family:
In-Network (Tier 1)
Individual: $3,000 (employee only coverage) or $3,300 (family coverage)
Family: $6,000
Individual: $3,000 (employee only coverage) or $3,300 (family coverage)
Family: $6,000
In-Network (Tier 2)
Individual: $4,000
Family: $8,000
Individual: $4,000
Family: $8,000
Out-of-Network
Individual: $6,000
Family: $12,000
Individual: $6,000
Family: $12,000
In-Network
Individual: None
Family:
Individual: None
Family:
In-Network
Individual: $2,000.00
Family:
Individual: $2,000.00
Family:
Out-of-Network
Individual: $1,500.00
Family:
Individual: $1,500.00
Family:
In- or Out-of-Network
Individual: $2,500.00
Family: $5,000.00
Individual: $2,500.00
Family: $5,000.00
—
In-Network (Tier 1)
Individual: $3,000.00
Family: $6,000.00
Individual: $3,000.00
Family: $6,000.00
In-Network (Tier 2)
Individual: $4,000.00
Family: $8,000
Individual: $4,000.00
Family: $8,000
Out-of-Network
Individual: $6,000
Family: $12,000
Individual: $6,000
Family: $12,000
In-Network (Tier 1)
Individual: $1,500.00
Family: $3,000.00
Individual: $1,500.00
Family: $3,000.00
In-Network (Tier 2)
Individual: $2,000
Family: $4,000
Individual: $2,000
Family: $4,000
In-Network (Tier 1)
Individual: $2,500
Family: $5,000
Individual: $2,500
Family: $5,000
In-Network (Tier 2)
Individual: $3,200
Family: $6,400
Individual: $3,200
Family: $6,400
Out-of-Network
Individual: $6,000
Family: $12,000
Individual: $6,000
Family: $12,000
In-Network
Individual: $3,200
Family: $6,400
Individual: $3,200
Family: $6,400
Out-of-Network
Individual: $6,000
Family: $12,000
Individual: $6,000
Family: $12,000
In-Network
Individual: $3,200
Family: $6,400
Individual: $3,200
Family: $6,400
Out-of-Network
Individual: $6,000
Family: $12,000
Individual: $6,000
Family: $12,000
—
Services
Exam (Once every calendar year)
Comprehensive Vision Exam
—
—
—
—
—
—
—
—
—
—
—
—
—
In-Network
$10 copayment
Out-of-Network
100% with reimbursement up to $45
$10 copayment
Out-of-Network
100% with reimbursement up to $45
—
—
—
—
—
—
—
—
—
—
—
—
—
In-Network
$10 copayment
Out-of-Network
100% with reimbursement up to $45
$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
$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
$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
$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
$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
$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
$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
$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
$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
$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
$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, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $70
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, one $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, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $70
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, one $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
Copayment not to exceed $60
Out-of-Network
Not covered
—
—
—
—
—
—
—
—
—
—
—
—
—
In-Network
Copayment not to exceed $60
Out-of-Network
Not covered
Copayment not to exceed $60
Out-of-Network
Not covered
Fitting Costs
—
—
—
—
—
—
—
—
—
—
—
—
—
In-Network
Copayment not to exceed $60
Out-of-Network
Not covered
Copayment not to exceed $60
Out-of-Network
Not covered
—
—
—
—
—
—
—
—
—
—
—
—
—
In-Network
Copayment not to exceed $60
Out-of-Network
Not covered
Copayment not to exceed $60
Out-of-Network
Not covered
Materials
—
—
—
—
—
—
—
—
—
—
—
—
—
In- or Out-of-Network
100% reimbursement up to $140
100% reimbursement up to $140
—
—
—
—
—
—
—
—
—
—
—
—
—
In- or Out-of-Network
100% reimbursement up to $140
100% reimbursement up to $140
Preventive & Diagnostic Services
Examinations & Visits
—
In- or Out-of-Network
Reimbursement based on 100% of in-network charge
Reimbursement based on 100% of in-network charge
—
In-Network
$0
$0
—
In-Network
$0
Out-of-Network
$0
$0
Out-of-Network
$0
—
—
—
—
—
—
—
—
—
—
In- or Out-of-Network
Reimbursement based on 100% of in-network charge
Reimbursement based on 100% of in-network charge
—
In-Network
$0
$0
In-Network
$0
Out-of-Network
$0
$0
Out-of-Network
$0
—
—
—
—
—
—
—
—
X-Ray Services
—
In- or Out-of-Network
Reimbursement based on 100% of in-network charge
Reimbursement based on 100% of in-network charge
—
In-Network
$0
$0
—
In-Network
$0
Out-of-Network
$0
$0
Out-of-Network
$0
—
—
—
—
—
—
—
—
—
—
In- or Out-of-Network
Reimbursement based on 100% of in-network charge
Reimbursement based on 100% of in-network charge
—
In-Network
$0
$0
In-Network
$0
Out-of-Network
$0
$0
Out-of-Network
$0
—
—
—
—
—
—
—
—
Cleanings
—
In- or Out-of-Network
Reimbursement based on 100% of in-network charge
Reimbursement based on 100% of in-network charge
—
In-Network
$0
$0
—
In-Network
$0
Out-of-Network
$0
$0
Out-of-Network
$0
—
—
—
—
—
—
—
—
—
—
In- or Out-of-Network
Reimbursement based on 100% of in-network charge
Reimbursement based on 100% of in-network charge
—
In-Network
$0
$0
In-Network
$0
Out-of-Network
$0
$0
Out-of-Network
$0
—
—
—
—
—
—
—
—
Flouride Treatments
—
In- or Out-of-Network
Reimbursement based on 100% of in-network charge
Reimbursement based on 100% of in-network charge
—
In-Network
$0
$0
—
In-Network
$0
Out-of-Network
$0
$0
Out-of-Network
$0
—
—
—
—
—
—
—
—
—
—
In- or Out-of-Network
Reimbursement based on 100% of in-network charge
Reimbursement based on 100% of in-network charge
—
In-Network
$0
$0
In-Network
$0
Out-of-Network
$0
$0
Out-of-Network
$0
—
—
—
—
—
—
—
—
Basic Services
Amalgam (Silver) Fillings
—
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
In-Network
$0
$0
—
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
—
—
—
—
—
—
—
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
In-Network
$0
$0
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
—
—
—
—
—
Root Canal Therapy (Anterior Teeth)
—
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
In-Network
$0
$0
—
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
—
—
—
—
—
—
—
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
In-Network
$0
$0
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
—
—
—
—
—
Root Canal Therapy (Molars)
—
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
—
—
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
—
—
—
—
—
—
—
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
—
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
—
—
—
—
—
Composite Fillings (Anterior Teeth)
—
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
In-Network
$0
$0
—
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
—
—
—
—
—
—
—
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
In-Network
$0
$0
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
—
—
—
—
—
Stainless Steel Crowns
—
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
In-Network
$0
$0
—
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
—
—
—
—
—
—
—
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
In-Network
$0
$0
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
—
—
—
—
—
Uncomplicated Extractions
—
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
In-Network
$0
$0
—
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
—
—
—
—
—
—
—
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
In-Network
$0
$0
In-Network
20%
Out-of-Network
30%
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
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
—
In-Network
40%
40%
—
In-Network
40%
Out-of-Network
50%
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
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
—
In-Network
40%
40%
In-Network
40%
Out-of-Network
50%
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
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
—
In-Network
40%
40%
—
In-Network
40%
Out-of-Network
50%
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
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
—
In-Network
40%
40%
In-Network
40%
Out-of-Network
50%
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
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
—
In-Network
40%
40%
—
In-Network
40%
Out-of-Network
50%
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
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
—
In-Network
40%
40%
In-Network
40%
Out-of-Network
50%
40%
Out-of-Network
50%
—
—
—
—
—
—
—
—
Root Canal Therapy (Molars)
—
—
—
In-Network
40%
40%
—
—
—
—
—
—
—
—
—
—
—
—
—
—
In-Network
40%
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
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
—
In-Network
40%
40%
—
In-Network
40%
Out-of-Network
50%
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
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
—
In-Network
40%
40%
In-Network
40%
Out-of-Network
50%
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
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
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
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
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
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
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
Maximum allowable charge
—
In-Network
Negotiated fee
Negotiated fee
—
In-Network
Negotiated fee
Out-of-Network
80th percentile of reasonable and customary charges
Negotiated fee
Out-of-Network
80th percentile of reasonable and customary charges
—
—
—
—
—
—
—
—
—
—
In- or Out-of-Network
Maximum allowable charge
Maximum allowable charge
—
In-Network
Negotiated fee
Negotiated fee
In-Network
Negotiated fee
Out-of-Network
80th percentile of reasonable and customary charges
Negotiated fee
Out-of-Network
80th percentile of reasonable and customary charges
—
—
—
—
—
—
—
—
Physician Visits
Telemedicine (Offered through Teladoc)
In-Network
$0
Out-of-Network
NA
$0
Out-of-Network
NA
—
In-Network
$0
Out-of-Network
NA
$0
Out-of-Network
NA
—
In-Network
$0
$0
—
In- or Out-of-Network
$40 until deductible is met, then 20% after deductible
$40 until deductible is met, then 20% after deductible
—
In-Network
$49 until deductible is met, then 100% after deductible
Out-of-Network
NA
$49 until deductible is met, then 100% after deductible
Out-of-Network
NA
In-Network
$0
Out-of-Network
NA
$0
Out-of-Network
NA
In-Network
$0
$0
In-Network
$0
Out-of-Network
NA
$0
Out-of-Network
NA
In-Network
$0
Out-of-Network
NA
$0
Out-of-Network
NA
—
In-Network
$10 copayment
$10 copayment
In-Network
$10 copayment
Out-of-Network
NA
$10 copayment
Out-of-Network
NA
—
In-Network
$10 copay after deductible
Out-of-Network
NA
$10 copay after deductible
Out-of-Network
NA
—
—
In- or Out-of-Network
$40 until deductible is met, then 20% after deductible
$40 until deductible is met, then 20% after deductible
—
In-Network
$56 until deductible is met, then $10 copayment
Out-of-Network
NA
$56 until deductible is met, then $10 copayment
Out-of-Network
NA
In-Network
$10 copayment
$10 copayment
In-Network
$10 copayment
Out-of-Network
NA
$10 copayment
Out-of-Network
NA
In-Network
$10 copayment
Out-of-Network
NA
$10 copayment
Out-of-Network
NA
In-Network
$10 copayment
Out-of-Network
NA
$10 copayment
Out-of-Network
NA
—
Telemental Health (Offered through Teladoc)
In-Network
$20 copayment
Out-of-Network
NA
$20 copayment
Out-of-Network
NA
—
In-Network
20% after deductible
Out-of-Network
NA
20% after deductible
Out-of-Network
NA
—
In-Network
$10 copayment
$10 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network
20% after deductible
Out-of-Network
NA
20% after deductible
Out-of-Network
NA
In-Network
$20 copayment
Out-of-Network
NA
$20 copayment
Out-of-Network
NA
In-Network
$10 copayment
$10 copayment
In-Network
$20 copayment
Out-of-Network
NA
$20 copayment
Out-of-Network
NA
In-Network
$20 copayment
Out-of-Network
NA
$20 copayment
Out-of-Network
NA
—
In-Network
$10 copayment
$10 copayment
In-Network
$10 copayment
Out-of-Network
NA
$10 copayment
Out-of-Network
NA
—
In-Network
$10 copay after deductible
Out-of-Network
NA
$10 copay after deductible
Out-of-Network
NA
—
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network
$10 copayment after deductible
Out-of-Network
NA
$10 copayment after deductible
Out-of-Network
NA
In-Network
$10 copayment
$10 copayment
In-Network
$10 copayment
Out-of-Network
NA
$10 copayment
Out-of-Network
NA
In-Network
$10 copayment
Out-of-Network
NA
$10 copayment
Out-of-Network
NA
In-Network
$10 copayment
Out-of-Network
NA
$10 copayment
Out-of-Network
NA
—
Primary Care Physician (PCP)
In-Network
$20 copayment
Out-of-Network
40% after deductible
$20 copayment
Out-of-Network
40% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$20 copayment
$20 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
In-Network
$20 copayment
Out-of-Network
40% after deductible
$20 copayment
Out-of-Network
40% after deductible
In-Network
$20 copayment
$20 copayment
In-Network
$20 copayment
Out-of-Network
40% after deductible
$20 copayment
Out-of-Network
40% after deductible
In-Network
$20 copayment
Out-of-Network
40% after deductible
$20 copayment
Out-of-Network
40% after deductible
—
In-Network (Tier 1)
$15 copayment
In-Network (Tier 2)
$30 copayment
$15 copayment
In-Network (Tier 2)
$30 copayment
In-Network (Tier 1)
$20 copayment
In-Network (Tier 2)
$35 copayment
Out-of-Network
40% after deductible
$20 copayment
In-Network (Tier 2)
$35 copayment
Out-of-Network
40% after deductible
—
In-Network (Tier 1)
$15 copay after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
$15 copay after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
—
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network (Tier 1)
$15 copayment after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
$15 copayment after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
In-Network (Tier 1)
$15 copayment
In-Network (Tier 2)
$30 copayment
$15 copayment
In-Network (Tier 2)
$30 copayment
In-Network (Tier 1)
$20 copayment
In-Network (Tier 2)
$35 copayment
Out-of-Network
40% after deductible
$20 copayment
In-Network (Tier 2)
$35 copayment
Out-of-Network
40% after deductible
In-Network
$25 copayment
Out-of-Network
40% after deductible
$25 copayment
Out-of-Network
40% after deductible
In-Network
$25 copayment
Out-of-Network
40% after deductible
$25 copayment
Out-of-Network
40% after deductible
—
Preventive Care & Immunizations
In-Network
$0
Out-of-Network
40% after deductible
$0
Out-of-Network
40% after deductible
—
In-Network
$0
Out-of-Network
50% after deductible
$0
Out-of-Network
50% after deductible
—
In-Network
$0
$0
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network
$0
Out-of-Network
50% after deductible
$0
Out-of-Network
50% after deductible
In-Network
$0
Out-of-Network
40% after deductible
$0
Out-of-Network
40% after deductible
In-Network
$0
$0
In-Network
$0
Out-of-Network
40% after deductible
$0
Out-of-Network
40% after deductible
In-Network
$0
Out-of-Network
40% after deductible
$0
Out-of-Network
40% after deductible
—
In-Network
$0
$0
In-Network
$0
Out-of-Network
40% after deductible
$0
Out-of-Network
40% after deductible
—
In-Network
$0
Out-of-Network
50% after deductible
$0
Out-of-Network
50% after deductible
—
—
In-Network
100%
100%
—
In-Network
$0
Out-of-Network
50% after deductible
$0
Out-of-Network
50% after deductible
In-Network
$0
$0
In-Network
$0
Out-of-Network
40% after deductible
$0
Out-of-Network
40% after deductible
In-Network
$0
Out-of-Network
40% after deductible
$0
Out-of-Network
40% after deductible
In-Network
$0
Out-of-Network
40% after deductible
$0
Out-of-Network
40% after deductible
—
Specialists
In-Network
$35 copayment
Out-of-Network
40% after deductible
$35 copayment
Out-of-Network
40% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
In-Network
$35 copayment
Out-of-Network
40% after deductible
$35 copayment
Out-of-Network
40% after deductible
In-Network
$25 copayment
$25 copayment
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
—
In-Network (Tier 1)
$20 copayment
In-Network (Tier 2)
$40 copayment
$20 copayment
In-Network (Tier 2)
$40 copayment
In-Network (Tier 1)
$30 copayment
In-Network (Tier 2)
$45copayment
Out-of-Network
40% after deductible
$30 copayment
In-Network (Tier 2)
$45copayment
Out-of-Network
40% after deductible
—
In-Network (Tier 1)
$25 copay after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
$25 copay after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
—
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network (Tier 1)
$25 copayment after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
$25 copayment after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
In-Network (Tier 1)
$20 copayment
In-Network (Tier 2)
$40 copayment
$20 copayment
In-Network (Tier 2)
$40 copayment
In-Network (Tier 1)
$30 copayment
In-Network (Tier 2)
$45 copayment
Out-of-Network
40% after deductible
$30 copayment
In-Network (Tier 2)
$45 copayment
Out-of-Network
40% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
—
Tiered Specialists
—
—
—
—
—
—
—
—
—
—
—
In-Network (Tier 1)
$30 copayment
In-Network (Tier 2)
$60 copayment
Out-of-Network
40% after deductible
$30 copayment
In-Network (Tier 2)
$60 copayment
Out-of-Network
40% after deductible
In-Network (Tier 1)
$30 copayment
In-Network (Tier 2)
$60 copayment
Out-of-Network
40% after deductible
$30 copayment
In-Network (Tier 2)
$60 copayment
Out-of-Network
40% after deductible
—
—
—
—
—
—
—
—
—
—
—
—
In-Network (Tier 1)
$30 copayment
In-Network (Tier 2)
$60 copayment
Out-of-Network
40% after deductible
$30 copayment
In-Network (Tier 2)
$60 copayment
Out-of-Network
40% after deductible
In-Network (Tier 1)
$30 copayment
In-Network (Tier 2)
$60 copayment
Out-of-Network
40% after deductible
$30 copayment
In-Network (Tier 2)
$60 copayment
Out-of-Network
40% after deductible
—
Emergency & Urgent Care Services
Urgent Care Center
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
—
In-Network
$0 after deductible
Out-of-Network
50% after deductible
$0 after deductible
Out-of-Network
50% after deductible
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network
$0 after deductible
Out-of-Network
50% after deductible
$0 after deductible
Out-of-Network
50% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
In-Network
$25 copayment
$25 copayment
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
—
In-Network
$25 copayment
$25 copayment
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
—
In-Network
$30 copay after deductible
Out-of-Network
50% after deductible
$30 copay after deductible
Out-of-Network
50% after deductible
—
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network
$30 copayment after deductible
Out-of-Network
50% after deductible
$30 copayment after deductible
Out-of-Network
50% after deductible
In-Network
$25 copayment
$25 copayment
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
—
Emergency Room (No coverage for non-emergencies)
In- or Out-of-Network
$175 copayment (waived if admitted)
$175 copayment (waived if admitted)
—
In- or Out-of-Network
$0 after deductible
$0 after deductible
—
In-Network
$175 copayment (waived if admitted)
$175 copayment (waived if admitted)
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In- or Out-of-Network
$0 after deductible
$0 after deductible
In- or Out-of-Network
$175 copayment (waived if admitted)
$175 copayment (waived if admitted)
In-Network
$175 copayment (waived if admitted)
$175 copayment (waived if admitted)
In- or Out-of-Network
$175 copayment (waived if admitted)
$175 copayment (waived if admitted)
In- or Out-of-Network
$175 copayment (waived if admitted)
$175 copayment (waived if admitted)
—
In-Network
$175 copayment (waived if admitted)
$175 copayment (waived if admitted)
In- or Out-of-Network
$175 copayment (waived if admitted)
$175 copayment (waived if admitted)
—
In- or Out-of-Network
$175 copay after deductible
$175 copay after deductible
—
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In- or Out-of-Network
$175 copayment after deductible
$175 copayment after deductible
In-Network
$175 copayment (waived if admitted)
$175 copayment (waived if admitted)
In- or Out-of-Network
$175 copayment (waived if admitted)
$175 copayment (waived if admitted)
In- or Out-of-Network
$175 copayment (waived if admitted)
$175 copayment (waived if admitted)
In- or Out-of-Network
$175 copayment (waived if admitted)
$175 copayment (waived if admitted)
—
Inpatient Services
Medical & Surgical Procedures
In-Network
10% after deductible
Out-of-Network
40% after deductible
10% after deductible
Out-of-Network
40% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$175 copayment
$175 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
In-Network
$500 copayment after deductible
Out-of-Network
40% after deductible
$500 copayment after deductible
Out-of-Network
40% after deductible
In-Network
$175 copayment
$175 copayment
In-Network
$500 copayment after deductible
Out-of-Network
40% after deductible
$500 copayment after deductible
Out-of-Network
40% after deductible
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
20% after deductible
Out-of-Network
40% after deductible
10% after deductible
In-Network (Tier 2)
20% after deductible
Out-of-Network
40% after deductible
—
In-Network (Tier 1)
$175 copayment
In-Network (Tier 2)
20% after deductible
$175 copayment
In-Network (Tier 2)
20% after deductible
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
40% after deductible
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
40% after deductible
—
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
—
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
In-Network (Tier 1)
$175 copayment
In-Network (Tier 2)
20% after deductible
$175 copayment
In-Network (Tier 2)
20% after deductible
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
40% after deductible
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
40% after deductible
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
40% after deductible
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
40% after deductible
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
20% after deductible
Out-of-Network
40% after deductible
10% after deductible
In-Network (Tier 2)
20% after deductible
Out-of-Network
40% after deductible
—
Mental Health
In-Network
10% after deductible
Out-of-Network
40% after deductible
10% after deductible
Out-of-Network
40% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$175 copayment
$175 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
In-Network
10% after deductible
Out-of-Network
40% after deductible
10% after deductible
Out-of-Network
40% after deductible
In-Network
$175 copayment
$175 copayment
In-Network
10% after deductible
Out-of-Network
40% after deductible
10% after deductible
Out-of-Network
40% after deductible
In-Network
10% after deductible
Out-of-Network
40% after deductible
10% after deductible
Out-of-Network
40% after deductible
—
In-Network (Tier 1)
$175 copayment
In-Network (Tier 2)
$175 copayment after deductible
$175 copayment
In-Network (Tier 2)
$175 copayment after deductible
In-Network
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
40% after deductible
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
40% after deductible
—
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
—
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
13% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Tier 2)
13% after deductible
Out-of-Network
50% after deductible
In-Network (Tier 1)
$175 copayment
In-Network (Tier 2)
$175 copayment after deductible
$175 copayment
In-Network (Tier 2)
$175 copayment after deductible
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
40% after deductible
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
40% after deductible
In-Network
10% after deductible
Out-of-Network
40% after deductible
10% after deductible
Out-of-Network
40% after deductible
In-Network
10% after deductible
Out-of-Network
40% after deductible
10% after deductible
Out-of-Network
40% after deductible
—
Outpatient Services
Surgical Procedures
In-Network
$500 copay after deductible
Out-of-Network
40% after deductible
$500 copay after deductible
Out-of-Network
40% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$30 (Independent Facility) / $75 copayment (Hospital)
$30 (Independent Facility) / $75 copayment (Hospital)
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
In-Network
$500 copay after deductible
Out-of-Network
40% after deductible
$500 copay after deductible
Out-of-Network
40% after deductible
In-Network
$15 copayment (Independent Facility) / $75 copayment (Hospital)
$15 copayment (Independent Facility) / $75 copayment (Hospital)
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
20% after deductible
Out-of-Network
40% after deductible
10% after deductible
In-Network (Tier 2)
20% after deductible
Out-of-Network
40% after deductible
In-Network
$500 copay after deductible
Out-of-Network
40% after deductible
$500 copay after deductible
Out-of-Network
40% after deductible
—
In-Network (Tier 1)
$30 copayment
In-Network (Tier 2)
$75 copayment after deductible
$30 copayment
In-Network (Tier 2)
$75 copayment after deductible
In-Network (Tier 1)
$250 copay after deductible
In-Network (Tier 2)
$500 copay after deductible
Out-of-Network
40% after deductible
$250 copay after deductible
In-Network (Tier 2)
$500 copay after deductible
Out-of-Network
40% after deductible
—
In-Network (Tier 1)
$250 copay after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
$250 copay after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
—
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network (Tier 1)
$250 copayment after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
$250 copayment after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
In-Network (Tier 1)
$30 copayment
In-Network (Tier 2)
$75 copayment after deductible
$30 copayment
In-Network (Tier 2)
$75 copayment after deductible
In-Network (Tier 1)
$250 copay after deductible
In-Network (Tier 2)
$500 copay after deductible
Out-of-Network
40% after deductible
$250 copay after deductible
In-Network (Tier 2)
$500 copay after deductible
Out-of-Network
40% after deductible
In-Network
$500 copay after deductible
Out-of-Network
40% after deductible
$500 copay after deductible
Out-of-Network
40% after deductible
In-Network
$500 copay after deductible
Out-of-Network
40% after deductible
$500 copay after deductible
Out-of-Network
40% after deductible
—
Laboratory
In-Network (Tier 1)
$0
In-Network (Tier 2)
40%
Out-of-Network
Not covered
$0
In-Network (Tier 2)
40%
Out-of-Network
Not covered
—
In-Network (Tier 1)
$0 after deductible
In-Network (Tier 2)
40% after deductible
Out-of-Network
Not covered
$0 after deductible
In-Network (Tier 2)
40% after deductible
Out-of-Network
Not covered
—
In-Network
$15
$15
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network (Tier 1)
$0 after deductible
In-Network (Tier 2)
40% after deductible
Out-of-Network
Not covered
$0 after deductible
In-Network (Tier 2)
40% after deductible
Out-of-Network
Not covered
In-Network (Tier 1)
$0 copayment
In-Network (Tier 2)
40%
Out-of-Network
Not covered
$0 copayment
In-Network (Tier 2)
40%
Out-of-Network
Not covered
In-Network
$15 copayment
$15 copayment
In-Network (Tier 1)
$20 copayment
In-Network (Tier 2)
40%
Out-of-Network
Not covered
$20 copayment
In-Network (Tier 2)
40%
Out-of-Network
Not covered
In-Network (Tier 1)
$20 copay
In-Network (Tier 2)
40%
Out-of-Network
Not covered
$20 copay
In-Network (Tier 2)
40%
Out-of-Network
Not covered
—
In-Network (Tier 1)
$10 copayment
In-Network (Tier 2)
$30 copayment
$10 copayment
In-Network (Tier 2)
$30 copayment
In-Network (Tier 1)
$20 copayment
In-Network (Tier 2)
$40 copayment
Out-of-Network
Not covered
$20 copayment
In-Network (Tier 2)
$40 copayment
Out-of-Network
Not covered
—
In-Network (Tier 1)
$10 copay after deductible
In-Network (Tier 2)
$30 copay after deductible
Out-of-Network
Not covered
$10 copay after deductible
In-Network (Tier 2)
$30 copay after deductible
Out-of-Network
Not covered
—
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network (Tier 1)
$10 copayment after deductible
In-Network (Tier 2)
$30 copayment after deductible
Out-of-Network
Not covered
$10 copayment after deductible
In-Network (Tier 2)
$30 copayment after deductible
Out-of-Network
Not covered
In-Network (Tier 1)
$10 copayment
In-Network (Tier 2)
$30 copayment
$10 copayment
In-Network (Tier 2)
$30 copayment
In-Network (Tier 1)
$20 copayment
In-Network (Tier 2)
$40 copayment
Out-of-Network
Not covered
$20 copayment
In-Network (Tier 2)
$40 copayment
Out-of-Network
Not covered
In-Network (Tier 1)
$20 copayment
In-Network (Tier 2)
$40 copayment
Out-of-Network
Not covered
$20 copayment
In-Network (Tier 2)
$40 copayment
Out-of-Network
Not covered
In-Network (Tier 1)
$20 copay
In-Network (Tier 2)
$40 copay
Out-of-Network
Not covered
$20 copay
In-Network (Tier 2)
$40 copay
Out-of-Network
Not covered
—
Radiology (X-Ray)
In-Network
$20 (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
$20 (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
$0 after deductible (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
—
In-Network
$15 (Independent Facility) / $50 copayment (Hospital)
$15 (Independent Facility) / $50 copayment (Hospital)
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network
$0 after deductible (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
$0 after deductible (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
In-Network
$20 copay (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
$20 copay (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
In-Network
$15 (Independent Facility) / $50 copayment (Hospital)
$15 (Independent Facility) / $50 copayment (Hospital)
In-Network
$20 copayment (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
$20 copayment (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
In-Network
$20 copay (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
$20 copay (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
—
In-Network (Tier 1)
$15 copayment
In-Network (Tier 2)
$35 copayment
$15 copayment
In-Network (Tier 2)
$35 copayment
In-Network (Tier 1)
$20 copayment
In-Network (Tier 2)
30% after deductible
Out-of-Network
Not covered
$20 copayment
In-Network (Tier 2)
30% after deductible
Out-of-Network
Not covered
—
In-Network (Tier 1)
$15 copay after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
Not covered
$15 copay after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
Not covered
—
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network (Tier 1)
$15 copayment after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
Not covered
$15 copayment after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
Not covered
In-Network (Tier 1)
$15 copayment
In-Network (Tier 2)
$35 copayment
$15 copayment
In-Network (Tier 2)
$35 copayment
In-Network (Tier 1)
$20 copay
In-Network (Tier 2)
30% after deductible
Out-of-Network
Not covered
$20 copay
In-Network (Tier 2)
30% after deductible
Out-of-Network
Not covered
In-Network
$20 copayment (Independent Facility) / 30% after deductible (Hospital)
Out-of-Network
Not covered
$20 copayment (Independent Facility) / 30% after deductible (Hospital)
Out-of-Network
Not covered
In-Network (Tier 1)
$20 copay (Independent Facility)
In-Network (Tier 2)
30% after deductible
Out-of-Network
Not covered
$20 copay (Independent Facility)
In-Network (Tier 2)
30% after deductible
Out-of-Network
Not covered
—
Hi-Tech Radiology (MRI, CAT, etc.)
In-Network (Tier 1)
$20 (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
$20 (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
$0 after deductible (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
—
In-Network
$15 (Independent Facility) / $100 copayment (Hospital)
$15 (Independent Facility) / $100 copayment (Hospital)
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network
$0 after deductible (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
$0 after deductible (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
In-Network (Tier 1)
$20 copayment (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
$20 copayment (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
In-Network
$0 (Independent Facility) / $100 copayment (Hospital)
$0 (Independent Facility) / $100 copayment (Hospital)
In-Network (Tier 1)
$20 copayment (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
$20 copayment (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
In-Network (Tier 1)
$20 copay (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
$20 copay (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
—
In-Network (Tier 1)
$15 copayment
In-Network (Tier 2)
$50 copayment
$15 copayment
In-Network (Tier 2)
$50 copayment
In-Network (Tier 1)
$20 copayment
In-Network (Tier 2)
30% after deductible
Out-of-Network
Not covered
$20 copayment
In-Network (Tier 2)
30% after deductible
Out-of-Network
Not covered
—
In-Network (Tier 1)
$15 copay after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
Not covered
$15 copay after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
Not covered
—
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network (Tier 1)
$15 copayment after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
Not covered
$15 copayment after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
Not covered
In-Network (Tier 1)
$15 copayment
In-Network (Tier 2)
$50 copayment
$15 copayment
In-Network (Tier 2)
$50 copayment
In-Network (Tier 1)
$20 copayment
In-Network (Tier 2)
30% after deductible
Out-of-Network
Not covered
$20 copayment
In-Network (Tier 2)
30% after deductible
Out-of-Network
Not covered
In-Network (Tier 1)
$20 copayment (Independent Facility) / 30% after deductible (Hospital)
Out-of-Network
Not covered
$20 copayment (Independent Facility) / 30% after deductible (Hospital)
Out-of-Network
Not covered
In-Network (Tier 1)
$20 copay (Independent Facility)
In-Network (Tier 2)
30% after deductible
Out-of-Network
Not covered
$20 copay (Independent Facility)
In-Network (Tier 2)
30% after deductible
Out-of-Network
Not covered
—
Mental Health
In-Network
$20 copayment
Out-of-Network
25% no deductible
$20 copayment
Out-of-Network
25% no deductible
—
In-Network
20% after deductible
Out-of-Network
25% after deductible
20% after deductible
Out-of-Network
25% after deductible
—
In-Network
$15 copayment
$15 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network
20% after deductible
Out-of-Network
25% after deductible
20% after deductible
Out-of-Network
25% after deductible
In-Network
$20 copayment
Out-of-Network
25% no deductible
$20 copayment
Out-of-Network
25% no deductible
In-Network
$15 copayment
$15 copayment
In-Network
$20 copayment
Out-of-Network
25% no deductible
$20 copayment
Out-of-Network
25% no deductible
In-Network
$20 copayment
Out-of-Network
25% no deductible
$20 copayment
Out-of-Network
25% no deductible
—
In-Network
$10 copayment
$10 copayment
In-Network
$20 copayment
Out-of-Network
25% no deductible
$20 copayment
Out-of-Network
25% no deductible
—
In-Network
$10 copayment after deductible
Out-of-Network
25% after deductible
$10 copayment after deductible
Out-of-Network
25% after deductible
—
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network
$10 copayment after deductible
Out-of-Network
25% after deductible
$10 copayment after deductible
Out-of-Network
25% after deductible
In-Network
$10 copayment
$10 copayment
In-Network
$20 copayment
Out-of-Network
25% no deductible
$20 copayment
Out-of-Network
25% no deductible
In-Network
$20 copayment
Out-of-Network
25% no deductible
$20 copayment
Out-of-Network
25% no deductible
In-Network
$20 copayment
Out-of-Network
25% no deductible
$20 copayment
Out-of-Network
25% no deductible
—
Annual Eye Exam
In- or Out-of-Network
Not covered
Not covered
—
In- or Out-of-Network
Not covered
Not covered
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
Not covered
Not covered
—
In- or Out-of-Network
Not covered
Not covered
In- or Out-of-Network
Not covered
Not covered
In-Network
$25 copayment
$25 copayment
In- or Out-of-Network
Not covered
Not covered
In- or Out-of-Network
Not covered
Not covered
—
In-Network (Tier 1)
$20 copayment
In-Network (Tier 2)
$40 copayment
$20 copayment
In-Network (Tier 2)
$40 copayment
In- or Out-of-Network
Not covered
Not covered
—
In- or Out-of-Network
Not covered
Not covered
—
—
In- or Out-of-Network
Not covered
Not covered
—
In- or Out-of-Network
Not covered
Not covered
In-Network (Tier 1)
$20 copayment
In-Network (Tier 2)
$40 copayment
$20 copayment
In-Network (Tier 2)
$40 copayment
In- or Out-of-Network
Not covered
Not covered
In- or Out-of-Network
Not covered
Not covered
In- or Out-of-Network
Not covered
Not covered
—
Prescription Eyeglasses and/or Contact Lenses
In- or Out-of-Network
Not covered
Not covered
—
In- or Out-of-Network
Not covered
Not covered
—
In-Network
$70 reimbursement every 2 years
$70 reimbursement every 2 years
—
In- or Out-of-Network
Not covered
Not covered
—
In- or Out-of-Network
Not covered
Not covered
In- or Out-of-Network
Not covered
Not covered
In-Network
$70 reimbursement every 2 years
$70 reimbursement every 2 years
In- or Out-of-Network
Not covered
Not covered
In- or Out-of-Network
Not covered
Not covered
—
In-Network
$70 reimbursement every 2 years
$70 reimbursement every 2 years
In- or Out-of-Network
Not covered
Not covered
—
In- or Out-of-Network
Not covered
Not covered
—
—
In- or Out-of-Network
Not covered
Not covered
—
In- or Out-of-Network
Not covered
Not covered
In-Network
$70 reimbursement every 2 years
$70 reimbursement every 2 years
In- or Out-of-Network
Not covered
Not covered
In- or Out-of-Network
Not covered
Not covered
In- or Out-of-Network
Not covered
Not covered
—
Physical Therapy
In-Network
10% after deductible
Out-of-Network
50% after deductible
10% after deductible
Out-of-Network
50% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$15 copayment
$15 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
In-Network
10% after deductible
Out-of-Network
50% after deductible
10% after deductible
Out-of-Network
50% after deductible
In-Network
$15 copayment
$15 copayment
In-Network
10% after deductible
Out-of-Network
50% after deductible
10% after deductible
Out-of-Network
50% after deductible
In-Network
10% after deductible
Out-of-Network
50% after deductible
10% after deductible
Out-of-Network
50% after deductible
—
In-Network (Tier 1)
$15 copayment
In-Network (Tier 2)
$30 copayment
$15 copayment
In-Network (Tier 2)
$30 copayment
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
—
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
—
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
In-Network (Tier 1)
$15 copayment
In-Network (Tier 2)
$30 copayment
$15 copayment
In-Network (Tier 2)
$30 copayment
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
In-Network
10% after deductible
Out-of-Network
50% after deductible
10% after deductible
Out-of-Network
50% after deductible
In-Network
10% after deductible
Out-of-Network
50% after deductible
10% after deductible
Out-of-Network
50% after deductible
—
Speech Therapy / Occupational Therapy / Pulmonary & Cardiac Rehabilitation
In-Network
10% after deductible
Out-of-Network
40% after deductible
10% after deductible
Out-of-Network
40% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
In-Network
10% after deductible
Out-of-Network
40% after deductible
10% after deductible
Out-of-Network
40% after deductible
In-Network
$25 copayment
$25 copayment
In-Network
10% after deductible
Out-of-Network
40% after deductible
10% after deductible
Out-of-Network
40% after deductible
In-Network
10% after deductible
Out-of-Network
40% after deductible
10% after deductible
Out-of-Network
40% after deductible
—
In-Network (Tier 1)
$15 copayment
In-Network (Tier 2)
$30 copayment
$15 copayment
In-Network (Tier 2)
$30 copayment
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
—
In-Network (Tier 2)
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
—
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
In-Network (Tier 1)
$15 copayment
In-Network (Tier 2)
$30 copayment
$15 copayment
In-Network (Tier 2)
$30 copayment
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
In-Network
10% after deductible
Out-of-Network
40% after deductible
10% after deductible
Out-of-Network
40% after deductible
In-Network
10% after deductible
Out-of-Network
50% after deductible
10% after deductible
Out-of-Network
50% after deductible
—
Chiropractic Care (20 visits per calendar year)
In-Network
$35 copayment
Out-of-Network
40% after deductible
$35 copayment
Out-of-Network
40% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
In-Network
$35 copayment
Out-of-Network
40% after deductible
$35 copayment
Out-of-Network
40% after deductible
In-Network
$25 copayment
$25 copayment
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
—
In-Network (Tier 1)
$20 copayment
In-Network (Tier 2)
$40 copayment
$20 copayment
In-Network (Tier 2)
$40 copayment
In-Network (Tier 1)
$30 copayment
In-Network (Tier 2)
$45 copayment
Out-of-Network
40% after deductible
$30 copayment
In-Network (Tier 2)
$45 copayment
Out-of-Network
40% after deductible
—
In-Network (Tier 1)
$25 copay after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
$25 copay after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
—
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network (Tier 1)
$25 copayment after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
$25 copayment after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
In-Network (Tier 1)
$20 copayment
In-Network (Tier 2)
$40 copayment
$20 copayment
In-Network (Tier 2)
$40 copayment
In-Network (Tier 1)
$30 copayment
In-Network (Tier 2)
$45copayment
Out-of-Network
40% after deductible
$30 copayment
In-Network (Tier 2)
$45copayment
Out-of-Network
40% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
—
Acupuncture (20 visits per calendar year)
In-Network
$35 copayment
Out-of-Network
40% after deductible
$35 copayment
Out-of-Network
40% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
In-Network
$35 copayment
Out-of-Network
40% after deductible
$35 copayment
Out-of-Network
40% after deductible
In-Network
$25 copayment
$25 copayment
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
—
In-Network (Tier 1)
$20 copayment
In-Network (Tier 2)
$40 copayment
$20 copayment
In-Network (Tier 2)
$40 copayment
In-Network (Tier 1)
$30 copayment
In-Network (Tier 2)
$45copayment
Out-of-Network
40% after deductible
$30 copayment
In-Network (Tier 2)
$45copayment
Out-of-Network
40% after deductible
—
In-Network (Tier 1)
$25 copay after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
$25 copay after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
—
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network (Tier 1)
$25 copayment after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
$25 copayment after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
In-Network (Tier 1)
$20 copayment
In-Network (Tier 2)
$40 copayment
$20 copayment
In-Network (Tier 2)
$40 copayment
In-Network (Tier 1)
$30 copayment
In-Network (Tier 2)
$45copayment
Out-of-Network
40% after deductible
$30 copayment
In-Network (Tier 2)
$45copayment
Out-of-Network
40% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
—
Maternity
Prenatal Care Visits
In-Network
$35 copayment for the first visit, $0 for subsequent visits
Out-of-Network
40% after deductible
$35 copayment for the first visit, $0 for subsequent visits
Out-of-Network
40% after deductible
—
In-Network
20% after deductible for the first visit, $0 for subsequent visits
Out-of-Network
50% after deductible
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
$25 copayment for first visit, $0 for subsequent visits
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network
20% after deductible for the first visit, $0 for subsequent visits
Out-of-Network
50% after deductible
20% after deductible for the first visit, $0 for subsequent visits
Out-of-Network
50% after deductible
In-Network
$35 copayment for the first visit, $0 for subsequent visits
Out-of-Network
40% after deductible
$35 copayment for the first visit, $0 for subsequent visits
Out-of-Network
40% after deductible
In-Network
$25 copayment for first visit, $0 for subsequent visits
$25 copayment for first visit, $0 for subsequent visits
In-Network (Tier 1)
$30 copayment for the first visit, $0 for subsequent visits
In-Network (Tier 2)
$60 copayment for the first visit, $0 for subsequent visits
Out-of-Network
40% after deductible
$30 copayment for the first visit, $0 for subsequent visits
In-Network (Tier 2)
$60 copayment for the first visit, $0 for subsequent visits
Out-of-Network
40% after deductible
In-Network (Tier 1)
$30 copayment for the first visit, $0 for subsequent visits
In-Network (Tier 2)
$60 copayment for the first visit, $0 for subsequent visits
Out-of-Network
40% after deductible
$30 copayment for the first visit, $0 for subsequent visits
In-Network (Tier 2)
$60 copayment for the first visit, $0 for subsequent visits
Out-of-Network
40% after deductible
—
In-Network (Tier 1)
$15 copayment for first visit, $0 for subsequent visits
In-Network (Tier 2)
$30 copayment for first visit, $0 for subsequent visits
$15 copayment for first visit, $0 for subsequent visits
In-Network (Tier 2)
$30 copayment for first visit, $0 for subsequent visits
In-Network (Tier 1)
$20 copayment for the first visit, $0 for subsequent visits
In-Network (Tier 2)
$35 copayment for the first visit, $0 for subsequent visits
Out-of-Network
40% after deductible
$20 copayment for the first visit, $0 for subsequent visits
In-Network (Tier 2)
$35 copayment for the first visit, $0 for subsequent visits
Out-of-Network
40% after deductible
—
In-Network (Tier 1)
$15 copay after deductible; $0 after deductible for subsequent visits
In-Network (Tier 2)
30% after deductible; $0 after deductible for subsequent visits
Out-of-Network
50% after deductible
$15 copay after deductible; $0 after deductible for subsequent visits
In-Network (Tier 2)
30% after deductible; $0 after deductible for subsequent visits
Out-of-Network
50% after deductible
—
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network (Tier 1)
$15 copayment after deductible for the first visit, $0 for subsequent visits
In-Network (Tier 2)
30% after deductible for the first visit, $0 for subsequent visits
Out-of-Network
50% after deductible
$15 copayment after deductible for the first visit, $0 for subsequent visits
In-Network (Tier 2)
30% after deductible for the first visit, $0 for subsequent visits
Out-of-Network
50% after deductible
In-Network
$15 copayment for first visit, $0 for subsequent visits
In-Network (Tier 2)
$30 copayment for first visit, $0 for subsequent visits
$15 copayment for first visit, $0 for subsequent visits
In-Network (Tier 2)
$30 copayment for first visit, $0 for subsequent visits
In-Network (Tier 1)
$20 copayment for the first visit, $0 for subsequent visits
In-Network (Tier 2)
$35 copayment for the first visit; $0 for subsequent visits
Out-of-Network
40% after deductible
$20 copayment for the first visit, $0 for subsequent visits
In-Network (Tier 2)
$35 copayment for the first visit; $0 for subsequent visits
Out-of-Network
40% after deductible
In-Network (Tier 1)
$30 copayment for the first visit, $0 for subsequent visits
In-Network (Tier 2)
$60 copayment for the first visit, $0 for subsequent visits
Out-of-Network
40% after deductible
$30 copayment for the first visit, $0 for subsequent visits
In-Network (Tier 2)
$60 copayment for the first visit, $0 for subsequent visits
Out-of-Network
40% after deductible
In-Network (Tier 1)
$30 copayment for the first visit, $0 for subsequent visits
In-Network (Tier 2)
$60 copayment for the first visit, $0 for subsequent visits
Out-of-Network
40% after deductible
$30 copayment for the first visit, $0 for subsequent visits
In-Network (Tier 2)
$60 copayment for the first visit, $0 for subsequent visits
Out-of-Network
40% after deductible
—
Delivery
In-Network
10% after deductible
Out-of-Network
40% after deductible
10% after deductible
Out-of-Network
40% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$175 copayment
$175 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
In-Network
10% after deductible
Out-of-Network
40% after deductible
10% after deductible
Out-of-Network
40% after deductible
In-Network
$175 copayment
$175 copayment
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
20% after deductible
Out-of-Network
40% after deductible
10% after deductible
In-Network (Tier 2)
20% after deductible
Out-of-Network
40% after deductible
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
20% after deductible
Out-of-Network
40% after deductible
10% after deductible
In-Network (Tier 2)
20% after deductible
Out-of-Network
40% after deductible
—
In-Network (Tier 1)
$175 copayment
In-Network (Tier 2)
20% after deductible
$175 copayment
In-Network (Tier 2)
20% after deductible
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
40% after deductible
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
40% after deductible
—
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
—
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
In-Network (Tier 1)
$175 copayment
In-Network (Tier 2)
20% after deductible
$175 copayment
In-Network (Tier 2)
20% after deductible
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
40% after deductible
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
40% after deductible
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
40% after deductible
10% after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
40% after deductible
In-Network (Tier 1)
10% after deductible
In-Network (Tier 2)
20% after deductible
Out-of-Network
40% after deductible
10% after deductible
In-Network (Tier 2)
20% after deductible
Out-of-Network
40% after deductible
—
Post-Partum Visits
In-Network
$35 copayment
Out-of-Network
40% after deductible
$35 copayment
Out-of-Network
40% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
In-Network
$35 copayment
Out-of-Network
40% after deductible
$35 copayment
Out-of-Network
40% after deductible
In-Network
$25 copayment
$25 copayment
In-Network (Tier 1)
$30 copayment
In-Network (Tier 2)
$60 copayment
Out-of-Network
40% after deductible
$30 copayment
In-Network (Tier 2)
$60 copayment
Out-of-Network
40% after deductible
In-Network (Tier 1)
$30 copayment
In-Network (Tier 2)
$60 copayment
Out-of-Network
40% after deductible
$30 copayment
In-Network (Tier 2)
$60 copayment
Out-of-Network
40% after deductible
—
In-Network (Tier 1)
$15 copayment
In-Network (Tier 2)
$30 copayment
$15 copayment
In-Network (Tier 2)
$30 copayment
In-Network (Tier 1)
$20 copayment
In-Network (Tier 2)
$35 copayment
Out-of-Network
40% after deductible
$20 copayment
In-Network (Tier 2)
$35 copayment
Out-of-Network
40% after deductible
—
In-Network (Tier 1)
$15 copay after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
$15 copay after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
—
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
In-Network (Tier 1)
$15 copay after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
$15 copay after deductible
In-Network (Tier 2)
30% after deductible
Out-of-Network
50% after deductible
In-Network (Tier 1)
$15 copayment
In-Network (Tier 2)
$30 copayment
$15 copayment
In-Network (Tier 2)
$30 copayment
In-Network
$20 copayment
In-Network (Tier 2)
$35 copayment
Out-of-Network
40% after deductible
$20 copayment
In-Network (Tier 2)
$35 copayment
Out-of-Network
40% after deductible
In-Network (Tier 1)
$30 copayment
In-Network (Tier 2)
$60 copayment
Out-of-Network
40% after deductible
$30 copayment
In-Network (Tier 2)
$60 copayment
Out-of-Network
40% after deductible
In-Network (Tier 1)
$30 copayment
In-Network (Tier 2)
$60 copayment
Out-of-Network
40% after deductible
$30 copayment
In-Network (Tier 2)
$60 copayment
Out-of-Network
40% after deductible
—