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Health Plan B - Low |
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Prefferred Provider
(In-Network Benefits)
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Non-Prefferred Provider
(Out-of-Network Benefits) |
Deductible per Policy Year
(Does not apply toward Out-of-Pocket Maximum) |
$1,500 per Insured
$4,500 per Family |
$5,000 per Insured
$15,000 per Family |
| Out-of-Pocket Maximum per Policy Year |
$5,000 per Insured
$12,500 per Family |
$15,000 per Insured
$30,000 per Family |
| Preauthorization Penalty |
Failure to preauthorize reduces benefits by 50% or $500, whichever is less. |
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| Doctor Office Visits |
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Office Visits |
$25 per visit |
50% after Deductible |
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Hospital Services |
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Inpatient Room & Board and other Inpatient charges |
70% after Deductible |
50% after Deductible |
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Outpatient Room Surgery Facility |
70% after Deductible |
50% after Deductible |
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Emergency Care Services |
70% after Deductible |
For more detailed information visit the plan documents:
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