BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Calendar Year Deductible
Individual
$2,000 per person
$4,000 per person
Family Maximum
$4,000 per family
$8,000 per family
Family Maximum Calculation Collective Deductible: All family members contribute towards the family deductible. An individual cannot have claims covered under the plan coinsurance until the total family deductible has been satisfied. Combined Medical/Pharmacy Calendar Year Deductible Combined Medical/Pharmacy Deductible: includes retail and home delivery drugs Home Delivery Pharmacy Costs Contribute to the Combined Medical/Pharmacy Deductible Combined Out-of-Pocket Maximum for Medical and Pharmacy expenses
Yes
Yes
Yes
Yes
Individual – Employee Only
$5,000 per person
$10,000 per person
Individual – within a Family
$6,900 per person
$13,800 per person
Family Maximum
$10,000 per family
$20,000 per family
Family Maximum Calculation Individual Calculation:
Family members meet only their individual Out-of-Pocket and then their claims will be covered at 100%; if the family Out-of-Pocket has been met prior to their individual Out-of- Pocket being met, their claims will be paid at 100%.
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