Schedule of Benefits 2025
(Benefit Coverage Plans A and B)
Download a PDF Copy| Benefit | Benefit Coverage Plan A | Benefit Coverage Plan B | |||
|---|---|---|---|---|---|
| In-Network | Out-of-Network | In-Network | Out-of-Network | ||
| Financial | Deductible | None | $250 Individual; $500 Family | None | $300 Individual; $600 Family |
| Maximum out-of-pocket cost (does not include charges in excess of allowed amount or noncovered benefits) | $1,000 Individual; $2,000 Family copayment/coinsurance maximum | None | $1,000 Individual; $2,000 Family copayment/coinsurance maximum | None | |
| Coinsurance | None | 70%/30% | None | 70%/30% | |
| Reimbursement rate | None | 70th percentile | None | 70th percentile | |
| Preventive care | Well-child and well-adult visits | No cost | Paid at 70% of the allowed amount after deductible is met | No cost | Paid at 70% of the allowed amount after deductible is met |
| Well-woman visits | No cost | Paid at 70% of the allowed amount after deductible is met | No cost | Paid at 70% of the allowed amount after deductible is met | |
| Immunizations | No cost | Paid at 70% of the allowed amount after deductible is met | No cost | Paid at 70% of the allowed amount after deductible is met | |
| Benefit | Benefit Coverage Plan A | Benefit Coverage Plan B | |||
|---|---|---|---|---|---|
| In-Network | Out-of-Network | In-Network | Out-of-Network | ||
| Maternity Care | Routine obstetrical, prenatal care, delivery, and postnatal care for mother* | $10 copayment for initial visit only | Paid at 70% of the allowed amount after deductible is met | $10 copayment for initial visit only | Paid at 70% of the allowed amount after deductible is met |
| Inpatient Care | Room and board * | No cost | $500 copay/admission up to $1,000 max per individual or up to $2,000 max per family (deductible does not apply) Paid at 70% | No cost | $500 copay/admission up to $1,500 max per individual (deductible does not apply) Paid at 70% |
| Physician’s services* | No cost | Paid at 70% of the allowed amount after deductible is met | No cost | Paid at 70% of the allowed amount after deductible is met | |
| Surgery (Physician’s services)* | No cost | Paid at 70% of the allowed amount after deductible is met | No cost | Paid at 70% of the allowed amount after deductible is met | |
| Restorative physical and occupational therapy* | No cost | $500 copay/admission up to $1,000 max per individual or up to $2,000 max per family (deductible does not apply) Paid at 70% | No cost | $500 copay/admission up to $1,500 max per individual (deductible does not apply) Paid at 70% | |
| Skilled nursing facility (for up to 60 days per calendar year)* | No cost | $500 copay/admission up to $1,000 max per individual or up to $2,000 max per family (deductible does not apply) Paid at 70% | No cost | $500 copay/admission up to $1,500 max per individual (deductible does not apply) Paid at 70% | |
| Benefit | Benefit Coverage Plan A | Benefit Coverage Plan B | |||
|---|---|---|---|---|---|
| In-Network | Out-of-Network | In-Network | Out-of-Network | ||
| Outpatient Care | Office visits | $10 copay/visit PCP; $25 copay/visit specialist | Paid at 70% of the allowed amount after deductible is met | $10 copay/visit PCP; $30 copay/visit specialist | Paid at 70% of the allowed amount after deductible is met |
| Chiropractic care* | $10 copayment per visit | Paid at 70% of the allowed amount after deductible is met | $30 copayment per visit | Paid at 70% of the allowed amount after deductible is met | |
| Acupuncture | $25 copayment per visit | Paid at 70% of the allowed amount after deductible is met | $30 copayment per visit | Paid at 70% of the allowed amount after deductible is met | |
| Allergy treatment | $25 copayment per visit | Paid at 70% of the allowed amount after deductible is met | $30 copayment per visit | Paid at 70% of the allowed amount after deductible is met | |
| Restorative physical and occupational therapy* | $10 copayment per visit | Paid at 70% of the allowed amount after deductible is met | $30 copayment per visit | Paid at 70% of the allowed amount after deductible is met | |
| Cardiac rehabilitation* | $10 copayment per visit | Paid at 70% of the allowed amount after deductible is met | $30 copayment per visit | Paid at 70% of the allowed amount after deductible is met | |
| Radiology/imaging* | No cost | Paid at 70% of the allowed amount after deductible is met | $25 copayment | Paid at 70% of the allowed amount after deductible is met | |
| Laboratory tests* | No cost | Paid at 70% of the allowed amount after deductible is met | No cost | Paid at 70% of the allowed amount after deductible is met | |
| Restorative speech therapy for up to 30 visits per calendar year | $10 copayment per visit | Paid at 70% of the allowed amount after deductible is met | $30 copayment per visit | Paid at 70% of the allowed amount after deductible is met | |
| Surgery (physician’s services)* | No cost | Paid at 70% of the allowed amount after deductible is met | No cost | Paid at 70% of the allowed amount after deductible is met | |
| Surgery (facility charges)* | No cost | Paid at 70% after deductible is met | No cost | Paid at 70% after deductible is met | |
| Benefit | Benefit Coverage Plan A | Benefit Coverage Plan B | |||
|---|---|---|---|---|---|
| In-Network | Out-of-Network | In-Network | Out-of-Network | ||
| Other Services | Physician house calls | No cost | Paid at 70% of the allowed amount after deductible is met | No cost | Paid at 70% of the allowed amount after deductible is met |
| Home health care services (up to 140 visits per calendar year) | No cost | Paid at 70% (deductible does not apply) | No cost | Paid at 70% (deductible does not apply) | |
| Home hospice care (up to 210 days max combined with inpatient hospice care)* | No cost | Paid at 70% (deductible does not apply) | No cost | Paid at 70% (deductible does not apply) | |
| Inpatient hospice care (up to 210 days max combined with home hospice care)* | No cost | $500 copay/admission up to $1,000 max per individual or up to $2,000 max per family (deductible does not apply) Paid at 70% | No cost | $500 copay/admission up to $1,500 max per individual (deductible does not apply) Paid at 70% | |
| Durable medical equipment and supplies* | Paid at 80% of contracted amount | Paid at 70% of the cost of the covered item (deductible does not apply) | Paid at 80% of contracted amount | Paid at 70% of the cost of the covered item (deductible does not apply) | |
| In vitro fertilization services or covered fertility drugs+ (up to a $5,000 lifetime maximum benefit. May elect to use the $5,000 max for prescriptions, if desired.)*+ | No cost for IVF services; prescription copays may apply | Paid at 70% of the allowed amount after deductible is met | No cost for IVF services; prescription copays may apply | Paid at 70% of the allowed amount after deductible is met | |
| ER | At hospital emergency room (waived if admitted) | $75 copayment per visit | $100 copayment per visit | ||
| Benefit | Benefit Coverage Plan A | Benefit Coverage Plan B | |||
|---|---|---|---|---|---|
| In-Network | Out-of-Network | In-Network | Out-of-Network | ||
| Behavioral Health | Outpatient behavioral health | $10 copayment per visit | Paid at 70% of the allowed amount after deductible is met | $10 copayment per visit | Paid at 70% of the allowed amount after deductible is met |
| Inpatient behavioral health* | No cost | $500 copay/admission up to $1,000 max per individual or up to $2,000 max per family (deductible does not apply) Paid at 70% | No cost | $500 copay/admission up to $1,500 max per individual (deductible does not apply) Paid at 70% | |
| Substance Abuse | Outpatient medical rehabilitative care for substance abuse/alcohol addiction | $10 copayment per visit | Paid at 70% of the allowed amount after deductible is met | $10 copayment per visit | Paid at 70% of the allowed amount after deductible is met |
| Inpatient medical rehabilitative care for substance abuse/alcohol addiction* | No cost | $500 copay/admission up to $1,000 max per individual or up to $2,000 max per family (deductible does not apply) Paid at 70% | No cost | $500 copay/admission up to $1,500 max per individual (deductible does not apply) Paid at 70% | |
| Applied Behavior Analysis (ABA) | Outpatient ABA office visits* | $10 copayment per visit | Paid at 70% of the allowed amount after deductible is met | $10 copayment per visit | Paid at 70% of the allowed amount after deductible is met |
| Outpatient facility care for ABA* | No cost | Paid at 70% of the allowed amount after deductible is met | No cost | Paid at 70% of the allowed amount after deductible is met | |
*Prior authorization may be required
