This plan gives you the option to choose any provider when you need care, although as always, you will pay less out of pocket when you see a provider who is in-network. If you receive care from an out-of-network provider, you will be responsible for the difference between the covered amount and the actual charges and you may be responsible for filing claims.
| Choice Plus Coverage Information | ||
|---|---|---|
| Coverage | In Network | Out Of Network |
| General Services | ||
| Annual Deductible/Individual | $5,000 | $12,000 |
| Annual Deductible/Family | $10,000 | $24,000 |
| Annual Out-of-Pocket Limit/Individual | $8,050 | $12,500 |
| Annual Out-of-Pocket Limit/Family | $16,100 | $25,000 |
| Office Services | ||
| Office Visit/Exam | 40% After Deductible | 50% After Deductible |
| Specialist Visit | 40% After Deductible | 50% After Deductible |
| Urgent Care | 40% After Deductible | 50% After Deductible |
| Preventative Services | 100% Covered | 50% Coinsurance |
| Hospital Services | ||
| Inpatient Hospital | 40% After Deductible | 50% After Deductible |
| Outpatient Surgery | 40% After Deductible | 50% After Deductible |
| Emergency Room | 40% After Deductible | 50% After Deductible |
| Prescription Drugs | ||
| Retail (30-Days) Tier 1 | $10 After Deductible | $10 After Deductible |
| Retail (30-Days) Tier 2 | $35 After Deductible | $35 After Deductible |
| Retail (30-Days) Tier 3 | $60 After Deductible | $60 After Deductible |
| Mail Order (90-Day) | 2.5x Retail Copay | Not Covered |
