Insurance Provider
|
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LIG¼ÕÇØº¸Çè |
Life Maximum
|
$100,000 |
Unlimited |
Benefits
|
$100,000 |
$100,000
per Sickness or Injury |
Deductible
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Preferred Care:
$150 per Policy Year
|
$0 |
Non-Preferred Care:
$500 per Policy Year
|
Preferred :
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|
90% of the Negotiated Charge |
100% º¸Çè ȸ»ç¿¡¼ º¸»ó |
Non-Preferred:
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|
70% of the Negotiated Charge |
OUT OF POCKET MAXIMUMS
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Preferred Care:
Out-of-Pocket: $10,000
|
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Non-Preferred Care:
Out-of-Pocket: $20,000
|
Prescription Drug
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Çù·Â¾à±¹½Ã:
Preferred Care
100% of the Negotiated Charge after the applicable per prescription
Copay:
Generic Prescription Drug:
$10 Copay/Deductible
Brand Name Prescription Drug: $20 Copay/Deductible
Non-Formulary Brand name: $35 Copay/Deductible
up to $1,500 per Policy Year.
|
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ºñÇù·Â¾à±¹½Ã:
Non-Preferred Care
50% of the Reasonable Charge after the applicable per
prescription Deductible
Generic Prescription Drug:
$10 Copay/Deductible
Brand Name Prescription Drug: $20 Copay/Deductible
Non-Formulary Brand name: $35 Copay/Deductible
up to $1,500 per Policy Year.
|
Premium
(Annual) |
Student:$1,239
Spouse:$3,958
Child:$1,118
|
Student:$981
Spouse:$981
Child:$981 |