Medical Plan Summaries (Multi-Choice)
Multi-Choice© is a fully funded approach that gives employers the ability to offer a variety of plan options to their employees. For employers looking to build their benefit brand and meet the diverse needs of every employee, Multi-Choice© provides 24 different plan designs. All plans are ACA compliant and fall within one of the four medal levels. Plans include the UnitedHealthcare Choice Plus and Balanced Navigate networks as well as PPO and H.S.A options.
Filter medical plans by deductible.
| Metal Level | Platinum | Platinum | Gold | Gold | Gold | Gold | Gold | Gold | Silver | Silver | Silver | Silver | Silver | Gold | Silver | Silver | Silver | Silver | Silver | Silver | Silver | Silver | Silver | Bronze |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Network | Choice Plus | Navigate | Choice Plus | Choice Plus | Choice Plus | Choice Plus | Choice Plus | Navigate | Choice Plus | Choice Plus | Choice Plus | Non-Differential PPO | Choice Plus | Navigate | Choice Plus | Choice Plus | Choice Plus | Choice Plus | Navigate | Navigate | Navigate | Navigate | Navigate | Navigate |
| Plan ID | KR-7 | D7-X | KR-8 | KR-9 | KT-N | KT-O | KU-7 | D7-M | KT-P | KT-W | EK-8 - H.S.A. | KU-5 | KT-Y | D7-O | KT-R | KT-Q | KT-Z | KU-4 - H.S.A. | D7-P | D7-U | DN-X - H.S.A. | D7-Y | D7-T | DN-Z - H.S.A. |
| Rx Plan ID | 1T | 1T | 1O | 1O | 1O | 1O | 1O | 1O | 1P | 1P | HW | 1P | 1P | 1O | 1P | 1P | 1P | HW | 1P | 1P | HW | 1P | 1P | HV |
|
In-Network Out-of-Network |
In-Network Out-of-Network |
In-Network Out-of-Network |
In-Network Out-of-Network |
In-Network Out-of-Network |
In-Network Out-of-Network |
In-Network Out-of-Network |
In-Network Out-of-Network |
In-Network Out-of-Network |
In-Network Out-of-Network |
In-Network Out-of-Network |
Non-Differential |
In-Network Out-of-Network |
In-Network Out-of-Network |
In-Network Out-of-Network |
In-Network Out-of-Network |
In-Network Out-of-Network |
In-Network Out-of-Network |
In-Network Out-of-Network |
In-Network Out-of-Network |
In-Network Out-of-Network |
In-Network Out-of-Network |
In-Network Out-of-Network |
In-Network Out-of-Network |
|
| Co-Insurance |
90% 50% |
90% N/A |
80% 50% |
80% 50% |
80% 50% |
80% 50% |
70% 50% |
80% N/A |
80% 50% |
70% 50% |
80% 50% |
80% |
70% 50% |
80% N/A |
70% 50% |
70% 50% |
70% 50% |
80% 50% |
70% N/A |
70% N/A |
80% N/A |
70% N/A |
70% N/A |
70% N/A |
| Annual Deductible | ||||||||||||||||||||||||
| • Individual |
$100 $200 |
$100 N/A |
$500 $1,000 |
$750 $1,500 |
$1,000 $2,000 |
$1,500 $3,000 |
$500 $1,000 |
$500 N/A |
$2,000 $4,000 |
$1,000 $2,000 |
$1,500 $3,000 |
$1,500 |
$1,500 $3,000 |
$1,000 N/A |
$1,750 $3,500 |
$1,500 $3,000 |
$2,000 $4,000 |
$2,000 $4,000 |
$1,500 N/A |
$2,000 N/A |
$1,500 N/A |
$1,750 N/A |
$2,000 N/A |
$3,500 N/A |
| • Family |
$200 $400 |
$200 N/A |
$1,000 $2,000 |
$1,500 $3,000 |
$2,000 $4,000 |
$3,000 $6,000 |
$1,000 $2,000 |
$1,000 N/A |
$4,000 $8,000 |
$2,000 $4,000 |
$3,000 $6,000 |
$6,350 |
$3,000 $6,000 |
$2,000 N/A |
$3,500 $7,000 |
$3,000 $6,000 |
$4,000 $8,000 |
$4,000 $8,000 |
$3,000 N/A |
$4,000 N/A |
$3,000 N/A |
$3,500 N/A |
$4,000 N/A |
$7,000 N/A |
| Out-of-Pocket Maximum (Includes Co-Pays & Deductible) | ||||||||||||||||||||||||
| • Individual |
$2,500 $5,000 |
$2,500 N/A |
$4,000 $8,000 |
$4,000 $8,000 |
$4,000 $8,000 |
$4,000 $8,000 |
$4,000 $8,000 |
$4,000 N/A |
$6,350 $12,700 |
$6,350 $12,700 |
$5,000 $10,000 |
$3,000 |
$6,350 $12,700 |
$4,000 N/A |
$6,350 $12,700 |
$6,350 $12,700 |
$6,350 $12,700 |
$5,000 $10,000 |
$6,350 N/A |
$6,350 N/A |
$5,000 N/A |
$6,350 N/A |
$6,350 N/A |
$6,350 N/A |
| • Family |
$5,000 $10,000 |
$5,000 N/A |
$8,000 $16,000 |
$8,000 $16,000 |
$8,000 $16,000 |
$8,000 $16,000 |
$8,000 $16,000 |
$8,000 N/A |
$12,700 $25,400 |
$12,700 $25,400 |
$10,000 $20,000 |
$12,700 |
$12,700 $25,400 |
$8,000 N/A |
$12,700 $25,400 |
$12,700 $25,400 |
$12,700 $25,400 |
$10,000 $20,000 |
$12,700 N/A |
$12,700 N/A |
$10,000 N/A |
$12,700 N/A |
$12,700 N/A |
$12,700 N/A |
| Preventive Care Services | ||||||||||||||||||||||||
| • Office Visit |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
| • Lab, X-Ray Preventive Tests |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
| Professional Services | ||||||||||||||||||||||||
| • Primary Care Office Visits |
$10 Co-Pay Ded + 50% |
$10 Co-Pay N/A |
$25 Co-Pay Ded + 50% |
$20 Co-Pay Ded + 50% |
$25 Co-Pay Ded + 50% |
$20 Co-Pay Ded + 50% |
$25 Co-Pay Ded + 50% |
$25 Co-Pay N/A |
$30 Co-Pay Ded + 50% |
$35 Co-Pay Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
$30 Co-Pay Ded + 50% |
$25 Co-Pay N/A |
$30 Co-Pay Ded + 50% |
$40 Co-Pay Ded + 50% |
$35 Co-Pay Ded + 50% |
Ded + 20% Ded + 50% |
$30 Co-Pay N/A |
$30 Co-Pay N/A |
Ded + 20% N/A |
$35 Co-Pay N/A |
$40 Co-Pay N/A |
Ded + 30% N/A |
| • Specialist Office Visits |
$10 Co-Pay Ded + 50% |
$20 Co-Pay N/A |
$25 Co-Pay Ded + 50% |
$20 Co-Pay Ded + 50% |
$25 Co-Pay Ded + 50% |
$20 Co-Pay Ded + 50% |
$50 Co-Pay Ded + 50% |
$50 Co-Pay N/A |
$55 Co-Pay Ded + 50% |
$70 Co-Pay Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
$60 Co-Pay Ded + 50% |
$50 Co-Pay N/A |
$70 Co-Pay Ded + 50% |
$80 Co-Pay Ded + 50% |
$75 Co-Pay Ded + 50% |
Ded + 20% Ded + 50% |
$60 Co-Pay N/A |
$55 Co-Pay N/A |
Ded + 20% N/A |
$75 Co-Pay N/A |
$80 Co-Pay N/A |
Ded + 30% N/A |
| • Physician Fees - Medical & Surgical |
Ded + 10% Ded + 50% |
Ded + 10% N/A |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded +20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 20% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
| Outpatient Services | ||||||||||||||||||||||||
| • Surgery |
Ded + 10% Ded + 50% |
Ded + 10% N/A |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded +20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 20% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
| • Lab, X-Ray, & Diagnostics |
10% Ded + 50% |
10% N/A |
20% Ded + 50% |
20% Ded + 50% |
20% Ded + 50% |
20% Ded + 50% |
30% Ded + 50% |
20% N/A |
20% Ded + 50% |
30% Ded + 50% |
Ded + 20% Ded + 50% |
20% |
30% Ded + 50% |
20% N/A |
30% Ded + 50% |
30% Ded + 50% |
30% Ded + 50% |
Ded + 20% Ded + 50% |
30% N/A |
30% N/A |
Ded + 20% N/A |
30% N/A |
30% N/A |
Ded + 30% N/A |
| • CT Scans, MRI, Nuclear Medicine |
Ded + 10% Ded + 50% |
Ded + 10% N/A |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded +20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 20% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
| • Therapeutic Treatments |
Ded + 10% Ded + 50% |
Ded + 10% N/A |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded +20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 20% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
| Urgent Care |
$35 Co-Pay Ded + 50% |
$35 Co-Pay N/A |
$50 Co-Pay Ded + 50% |
$50 Co-Pay Ded + 50% |
$50 Co-Pay Ded + 50% |
$50 Co-Pay Ded + 50% |
$50 Co-Pay Ded + 50% |
$50 Co-Pay N/A |
$50 Co-Pay Ded + 50% |
$50 Co-Pay Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
$50 Co-Pay Ded + 50% |
$50 Co-Pay N/A |
$50 Co-Pay Ded + 50% |
$50 Co-Pay Ded + 50% |
$50 Co-Pay Ded + 50% |
Ded + 20% Ded + 50% |
$50 Co-Pay N/A |
$50 Co-Pay N/A |
Ded + 20% N/A |
$50 Co-Pay N/A |
$50 Co-Pay N/A |
Ded + 30% N/A |
| Hospital Facility | ||||||||||||||||||||||||
| • Emergency Room | Ded + 10% | Ded + 10% | Ded + 20% | Ded + 20% | Ded + 20% | Ded + 20% | Ded + 30% | Ded + 20% | Ded + 20% | Ded + 30% | Ded + 20% | Ded + 20% | Ded + 30% | Ded + 20% | Ded + 30% | Ded + 30% | Ded + 30% | Ded +20% | Ded + 30% | Ded + 30% | Ded + 20% | Ded + 30% | Ded + 30% | Ded + 30% |
| • Inpatient |
Ded + 10% Ded + 50% |
Ded + 10% N/A |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded +20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 20% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
| • Outpatient |
Ded + 10% Ded + 50% |
Ded + 10% N/A |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded +20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 20% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
| Ambulance Services | Ded + 10% | Ded + 10% | Ded + 20% | Ded + 20% | Ded + 20% | Ded + 20% | Ded + 30% | Ded + 20% | Ded + 20% | Ded + 30% | Ded + 20% | Ded + 20% | Ded + 30% | Ded + 20% | Ded + 30% | Ded + 30% | Ded + 30% | Ded +20% | Ded + 30% | Ded + 30% | Ded + 20% | Ded + 30% | Ded + 30% | Ded + 30% |
| Pregnancy - Maternity Services |
Ded + 10% Ded + 50% |
Ded + 10% N/A |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded +20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 20% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
| Transplantation Services |
Ded + 10% N/A |
Ded + 10% N/A |
Ded + 20% N/A |
Ded + 20% N/A |
Ded + 20% N/A |
Ded +20% N/A |
Ded + 30% N/A |
Ded + 20% N/A |
Ded + 20% N/A |
Ded + 30% N/A |
Ded + 20% N/A |
Ded + 20% |
Ded + 30% N/A |
Ded + 20% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 20% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 20% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
| Facility Care | ||||||||||||||||||||||||
| • Skilled Nursing Care - (Limit 60 Days) |
Ded + 10% Ded + 50% |
Ded + 10% N/A |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded +20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 20% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
| • Hospice Care |
Ded + 10% Ded + 50% |
Ded + 10% N/A |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded +20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 20% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
| Home Health Services |
Ded + 10% Ded + 50% |
Ded + 10% N/A |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded +20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 20% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
| Durable Medical Equipment |
Ded + 10% Ded + 50% |
Ded + 10% N/A |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded +20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 20% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
| Mental Health Services | ||||||||||||||||||||||||
| • Inpatient |
Ded + 10% Ded + 50% |
Ded + 10% N/A |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded +20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 20% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
| • Outpatient |
100% Ded + 50% |
100% N/A |
100% Ded + 50% |
100% Ded + 50% |
100% Ded + 50% |
100% Ded + 50% |
100% Ded + 50% |
100% N/A |
100% Ded + 50% |
100% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
100% Ded + 50% |
100% N/A |
100% Ded + 50% |
100% Ded + 50% |
100% Ded + 50% |
Ded + 20% Ded + 50% |
100% N/A |
100% N/A |
Ded + 20% N/A |
100% N/A |
100% N/A |
Ded + 30% N/A |
| Substance Use Disorders | ||||||||||||||||||||||||
| • Inpatient: Intermediate Care |
Ded + 10% Ded + 50% |
Ded + 10% N/A |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded +20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 20% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
| • Outpatient |
100% Ded + 50% |
100% N/A |
100% Ded + 50% |
100% Ded + 50% |
100% Ded + 50% |
100% Ded + 50% |
100% Ded + 50% |
100% N/A |
100% Ded + 50% |
100% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
100% Ded + 50% |
100% N/A |
100% Ded + 50% |
100% Ded + 50% |
100% Ded + 50% |
Ded + 20% Ded + 50% |
100% N/A |
100% N/A |
Ded + 20% N/A |
100% N/A |
100% N/A |
Ded + 30% N/A |
| Rehabilitation Services | ||||||||||||||||||||||||
| • Inpatient - (Limit 30 Days) |
Ded + 10% Ded + 50% |
Ded + 10% N/A |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded +20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 20% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
| • Outpatient - Limits vary based on service |
$10 Co-Pay Ded + 50% |
$10 Co-Pay N/A |
$25 Co-Pay Ded + 50% |
$20 Co-Pay Ded + 50% |
$25 Co-Pay Ded + 50% |
$20 Co-Pay Ded + 50% |
$25 Co-Pay Ded + 50% |
$25 Co-Pay N/A |
$30 Co-Pay Ded + 50% |
$35 Co-Pay Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
$30 Co-Pay Ded + 50% |
$25 Co-Pay N/A |
$30 Co-Pay Ded + 50% |
$40 Co-Pay Ded + 50% |
$35 Co-Pay Ded + 50% |
Ded + 20% Ded + 50% |
$30 Co-Pay N/A |
$30 Co-Pay N/A |
Ded + 20% N/A |
$35 Co-Pay N/A |
$40 Co-Pay N/A |
Ded + 30% N/A |
| Neurodevelopmental Therapy | ||||||||||||||||||||||||
| • Inpatient |
Ded + 10% Ded + 50% |
Ded + 10% N/A |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded +20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 20% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
| • Outpatient - Limit 25 Visits per Year |
$10 Co-Pay Ded + 50% |
$10 Co-Pay N/A |
$25 Co-Pay Ded + 50% |
$20 Co-Pay Ded + 50% |
$25 Co-Pay Ded + 50% |
$20 Co-Pay Ded + 50% |
$25 Co-Pay Ded + 50% |
$25 Co-Pay N/A |
$30 Co-Pay Ded + 50% |
$35 Co-Pay Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
$30 Co-Pay Ded + 50% |
$25 Co-Pay N/A |
$30 Co-Pay Ded + 50% |
$40 Co-Pay Ded + 50% |
$35 Co-Pay Ded + 50% |
Ded + 20% Ded + 50% |
$30 Co-Pay N/A |
$30 Co-Pay N/A |
Ded + 20% N/A |
$35 Co-Pay N/A |
$40 Co-Pay N/A |
Ded + 30% N/A |
| Alternative Care Services | ||||||||||||||||||||||||
| • Acupuncture - 12 Visits per Year |
$10 Co-Pay Ded + 50% |
$10 Co-Pay N/A |
$25 Co-Pay Ded + 50% |
$20 Co-Pay Ded + 50% |
$25 Co-Pay Ded + 50% |
$20 Co-Pay Ded + 50% |
$25 Co-Pay Ded + 50% |
$25 Co-Pay N/A |
$30 Co-Pay Ded + 50% |
$35 Co-Pay Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
$30 Co-Pay Ded + 50% |
$25 Co-Pay N/A |
$30 Co-Pay Ded + 50% |
$40 Co-Pay Ded + 50% |
$35 Co-Pay Ded + 50% |
Ded + 20% Ded + 50% |
$30 Co-Pay N/A |
$30 Co-Pay N/A |
Ded + 20% N/A |
$35 Co-Pay N/A |
$40 Co-Pay N/A |
Ded + 30% N/A |
| • Massage Therapy - 10 Visits per Year |
$10 Co-Pay Ded + 50% |
$10 Co-Pay N/A |
$25 Co-Pay Ded + 50% |
$20 Co-Pay Ded + 50% |
$25 Co-Pay Ded + 50% |
$20 Co-Pay Ded + 50% |
$25 Co-Pay Ded + 50% |
$25 Co-Pay N/A |
$30 Co-Pay Ded + 50% |
$35 Co-Pay Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
$30 Co-Pay Ded + 50% |
$25 Co-Pay N/A |
$30 Co-Pay Ded + 50% |
$40 Co-Pay Ded + 50% |
$35 Co-Pay Ded + 50% |
Ded + 20% Ded + 50% |
$30 Co-Pay N/A |
$30 Co-Pay N/A |
Ded + 20% N/A |
$35 Co-Pay N/A |
$40 Co-Pay N/A |
Ded + 30% N/A |
| • Manipulative Treatment- 12 Visits per Year |
$10 Co-Pay Ded + 50% |
$20 Co-Pay N/A |
$25 Co-Pay Ded + 50% |
$20 Co-Pay Ded + 50% |
$25 Co-Pay Ded + 50% |
$20 Co-Pay Ded + 50% |
$25 Co-Pay Ded + 50% |
$50 Co-Pay N/A |
$30 Co-Pay Ded + 50% |
$35 Co-Pay Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
$30 Co-Pay Ded + 50% |
$50 Co-Pay N/A |
$30 Co-Pay Ded + 50% |
$40 Co-Pay Ded + 50% |
$35 Co-Pay Ded + 50% |
Ded + 20% Ded + 50% |
$60 Co-Pay N/A |
$55 Co-Pay N/A |
Ded + 20% N/A |
$75 Co-Pay N/A |
$80 Co-Pay N/A |
Ded + 30% N/A |
| Hearing Aids - (Limit $5,000 per Year) |
Ded + 10% Ded + 50% |
Ded + 10% N/A |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% Ded + 50% |
Ded +20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 20% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 20% |
Ded + 30% Ded + 50% |
Ded + 20% N/A |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 30% Ded + 50% |
Ded + 20% Ded + 50% |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 20% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
Ded + 30% N/A |
| Prescription | ||||||||||||||||||||||||
| • Tier 1 | $10 Co-Pay |
$10 Co-Pay N/A |
$15 Co-Pay | $15 Co-Pay | $15 Co-Pay | $15 Co-Pay | $15 Co-Pay |
$15 Co-Pay N/A |
$20 Co-Pay | $20 Co-Pay | Ded + 20% | $20 Co-Pay | $20 Co-Pay |
$15 Co-Pay N/A |
$20 Co-Pay | $20 Co-Pay | $20 Co-Pay | Ded + 20% |
$20 Co-Pay N/A |
$20 Co-Pay N/A |
Ded + 20% N/A |
$20 Co-Pay N/A |
$20 Co-Pay N/A |
Ded + 30% N/A |
| • Tier 2 | $30 Co-Pay |
$30 Co-Pay N/A |
$35 Co-Pay | $35 Co-Pay | $35 Co-Pay | $35 Co-Pay | $35 Co-Pay |
$35 Co-Pay N/A |
$40 Co-Pay | $40 Co-Pay | Ded + 20% | $40 Co-Pay | $40 Co-Pay |
$35 Co-Pay N/A |
$40 Co-Pay | $40 Co-Pay | $40 Co-Pay | Ded + 20% |
$40 Co-Pay N/A |
$40 Co-Pay N/A |
Ded + 20% N/A |
$40 Co-Pay N/A |
$40 Co-Pay N/A |
Ded + 30% N/A |
| • Tier 3 | $50 Co-Pay |
$50 Co-Pay N/A |
$65 Co-Pay | $65 Co-Pay | $65 Co-Pay | $65 Co-Pay | $65 Co-Pay |
$65 Co-Pay N/A |
$80 Co-Pay | $80 Co-Pay | Ded + 20% | $80 Co-Pay | $80 Co-Pay |
$65 Co-Pay N/A |
$80 Co-Pay | $80 Co-Pay | $80 Co-Pay | Ded + 20% |
$80 Co-Pay N/A |
$80 Co-Pay N/A |
Ded + 20% N/A |
$80 Co-Pay N/A |
$80 Co-Pay N/A |
Ded + 30% N/A |
| • Tier 4 | $250 Co-Pay |
$250 Co-Pay N/A |
$250 Co-Pay | $250 Co-Pay | $250 Co-Pay | $250 Co-Pay | $250 Co-Pay |
$250 Co-Pay N/A |
$250 Co-Pay | $250 Co-Pay | Ded + 20% | $250 Co-Pay | $250 Co-Pay |
$250 Co-Pay N/A |
$250 Co-Pay | $250 Co-Pay | $250 Co-Pay | Ded + 20% |
$250 Co-Pay N/A |
$250 Co-Pay N/A |
Ded + 20% N/A |
$250 Co-Pay N/A |
$250 Co-Pay N/A |
Ded + 30% N/A |
| • Mail Service | 2.5 x Co-Pay |
2.5 x Co-Pay N/A |
2.5 x Co-Pay | 2.5 x Co-Pay | 2.5 x Co-Pay | 2.5 x Co-Pay | 2.5 x Co-Pay |
2.5 x Co-Pay N/A |
2.5 x Co-Pay | 2.5 x Co-Pay | Ded + 20% | 2.5 x Co-Pay | 2.5 x Co-Pay |
2.5 x Co-Pay N/A |
2.5 x Co-Pay | 2.5 x Co-Pay | 2.5 x Co-Pay | Ded + 20% |
2.5 x Co-Pay N/A |
2.5 x Co-Pay N/A |
Ded + 20% N/A |
2.5 x Co-Pay N/A |
2.5 x Co-Pay N/A |
Ded + 30% N/A |
| Pediatric Vision | ||||||||||||||||||||||||
| • Routine Vision Exam |
100% 100% to $30 |
100% N/A |
100% 100% to $30 |
100% 100% to $30 |
100% 100% to $30 |
100% 100% to $30 |
100% 100% to $30 |
100% N/A |
100% 100% to $30 |
100% 100% to $30 |
100% 100% to $30 |
100% 100% to $30 |
100% 100% to $30 |
100% N/A |
100% 100% to $30 |
100% 100% to $30 |
100% 100% to $30 |
100% 100% to $30 |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
| • Eyeglass Lenses - Single Vision |
100% 100% to $25 |
100% N/A |
100% 100% to $25 |
100% 100% to $25 |
100% 100% to $25 |
100% 100% to $25 |
100% 100% to $25 |
100% N/A |
100% 100% to $25 |
100% 100% to $25 |
100% 100% to $25 |
100% 100% to $25 |
100% 100% to $25 |
100% N/A |
100% 100% to $25 |
100% 100% to $25 |
100% 100% to $25 |
100% 100% to $25 |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
| • Eyeglass Lenses - Bifocal Lenses |
100% 100% to $35 |
100% N/A |
100% 100% to $35 |
100% 100% to $35 |
100% 100% to $35 |
100% 100% to $35 |
100% 100% to $35 |
100% N/A |
100% 100% to $35 |
100% 100% to $35 |
100% 100% to $35 |
100% 100% to $35 |
100% 100% to $35 |
100% N/A |
100% 100% to $35 |
100% 100% to $35 |
100% 100% to $35 |
100% 100% to $35 |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
| • Eyeglass Lenses - Trifocal Lenses |
100% 100% to $45 |
100% N/A |
100% 100% to $45 |
100% 100% to $45 |
100% 100% to $45 |
100% 100% to $45 |
100% 100% to $45 |
100% N/A |
100% 100% to $45 |
100% 100% to $45 |
100% 100% to $45 |
100% 100% to $45 |
100% 100% to $45 |
100% N/A |
100% 100% to $45 |
100% 100% to $45 |
100% 100% to $45 |
100% 100% to $45 |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
| • Eyeglass Lenses - Lenticular Lenses |
100% 100% to $45 |
100% N/A |
100% 100% to $45 |
100% 100% to $45 |
100% 100% to $45 |
100% 100% to $45 |
100% 100% to $45 |
100% N/A |
100% 100% to $45 |
100% 100% to $45 |
100% 100% to $45 |
100% 100% to $45 |
100% 100% to $45 |
100% N/A |
100% 100% to $45 |
100% 100% to $45 |
100% 100% to $45 |
100% 100% to $45 |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
| • Eyeglass Frames |
100% 100% to $30 |
100% N/A |
100% 100% to $30 |
100% 100% to $30 |
100% 100% to $30 |
100% 100% to $30 |
100% 100% to $30 |
100% N/A |
100% 100% to $30 |
100% 100% to $30 |
100% 100% to $30 |
100% 100% to $30 |
100% 100% to $30 |
100% N/A |
100% 100% to $30 |
100% 100% to $30 |
100% 100% to $30 |
100% 100% to $30 |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
| • Contact Lenses (Covered) |
100% 100% to $75 |
100% N/A |
100% 100% to $75 |
100% 100% to $75 |
100% 100% to $75 |
100% 100% to $75 |
100% 100% to $75 |
100% N/A |
100% 100% to $75 |
100% 100% to $75 |
100% 100% to $75 |
100% 100% to $75 |
100% 100% to $75 |
100% N/A |
100% 100% to $75 |
100% 100% to $75 |
100% 100% to $75 |
100% 100% to $75 |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
| • Contact Lenses (Necessary) |
100% 100% to $225 |
100% N/A |
100% 100% to $225 |
100% 100% to $225 |
100% 100% to $225 |
100% 100% to $225 |
100% 100% to $225 |
100% N/A |
100% 100% to $225 |
100% 100% to $225 |
100% 100% to $225 |
100% 100% to $225 |
100% 100% to $225 |
100% N/A |
100% 100% to $225 |
100% 100% to $225 |
100% 100% to $225 |
100% 100% to $225 |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
100% N/A |
| Pediatric Dental | ||||||||||||||||||||||||
| Annual Deductible | ||||||||||||||||||||||||
| • Individual |
Medical Ded Medical Ded |
Medical Ded N/A |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded N/A |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded N/A |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded N/A |
Medical Ded N/A |
Medical Ded N/A |
Medical Ded N/A |
Medical Ded N/A |
Medical Ded N/A |
| • Family |
Medical Ded Medical Ded |
Medical Ded N/A |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded N/A |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded N/A |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded Medical Ded |
Medical Ded N/A |
Medical Ded N/A |
Medical Ded N/A |
Medical Ded N/A |
Medical Ded N/A |
Medical Ded N/A |
| Preventive Services |
Ded + 100% Ded + 100% |
Ded + 100% N/A |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% N/A |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% N/A |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% N/A |
Ded + 100% N/A |
Ded + 100% N/A |
Ded + 100% N/A |
Ded + 100% N/A |
Ded + 100% N/A |
| • Diagnostics |
Ded + 100% Ded + 100% |
Ded + 100% N/A |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% N/A |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% N/A |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% Ded + 100% |
Ded + 100% N/A |
Ded + 100% N/A |
Ded + 100% N/A |
Ded + 100% N/A |
Ded + 100% N/A |
Ded + 100% N/A |
| • Basic Services |
Ded + 40% Ded + 40% |
Ded + 40% N/A |
Ded + 40% Ded + 40% |
Ded + 40% Ded + 40% |
Ded + 40% Ded + 40% |
Ded + 40% Ded + 40% |
Ded + 40% Ded + 40% |
Ded + 40% N/A |
Ded + 40% Ded + 40% |
Ded + 40% Ded + 40% |
Ded + 40% Ded + 40% |
Ded + 40% Ded + 40% |
Ded + 40% Ded + 40% |
Ded + 40% N/A |
Ded + 40% Ded + 40% |
Ded + 40% Ded + 40% |
Ded + 40% Ded + 40% |
Ded + 40% Ded + 40% |
Ded + 40% N/A |
Ded + 40% N/A |
Ded + 40% N/A |
Ded + 40% N/A |
Ded + 40% N/A |
Ded + 40% N/A |
| • Major Services |
Ded + 50% Ded + 50% |
Ded + 50% N/A |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% N/A |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% N/A |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% N/A |
Ded + 50% N/A |
Ded + 50% N/A |
Ded + 50% N/A |
Ded + 50% N/A |
Ded + 50% N/A |
| • Medical Necessary Orthodontics |
Ded + 50% Ded + 50% |
Ded + 50% N/A |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% N/A |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% N/A |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% Ded + 50% |
Ded + 50% N/A |
Ded + 50% N/A |
Ded + 50% N/A |
Ded + 50% N/A |
Ded + 50% N/A |
Ded + 50% N/A |
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