|
|
| BENEFITS |
ClearProtection Plus |
Calendar Year Deductible
(choose from 3 low-cost plans) |
All covered network and non-network services apply toword the deductibles below |
| Individual |
$1,000
or
$4,500 |
$3,300
or
$6,800 |
$5,000
or
$8,500 |
For Inpatient/Surgical and Emergency Room Services
or
For Outpatient/Professional and Diagnostic Services |
| Family |
$2,000
or
$9,000 |
$6,600
or
$13,600 |
$10,000
or
$17,000 |
For Inpatient/Surgical and Emergency Room Services
or
For Outpatient/Professional and Diagnostic Services |
| Network Coinsurance Options |
40%
0% |
40%
0% |
40%
0% |
For Inpatient/Surgical and Emergency Room Services
For Outpatient/Professional and Diagnostic Services |
| Calendar Year Out-of-Pocket Maximum |
All covered services, in any combination, apply toward your out-of-pocket maximum below.
This is the maximum you'll pay for most network covered services each calendar year; then the plan pays 100% |
| Individual |
$4,500 |
$6,800 |
$8,500 |
Network or Non-Network
(These amounts include the deductible) |
| Family |
$9,000 |
$13,600 |
$17,000 |
Network or Non-Network
(These amounts include the deductible) |
| Lifetime Maximum |
Unlimited |
| Covered Services |
Your share of costs (after deductible, if applicable) |
| Doctors' Office Visits |
NETWORK: First 2 office visits (per member): $40 copay, deductible waived
Additional office visits: 100% of negotiated fee; then 0% coinsurance after out-of-pocket max is met
NON-NETWORK: 100% Coinsurance; then 50% coinsurance after out-of-pocket maximum is met |
| Professional and Diagnostic Services (X-ray,lab,anesthesia,surgeon,etc.) |
NETWORK: Inpatient 40% Coinsurance
Outpatient: 100% of negotiated fee; then 0% coinsurance after out-of-pocket max is met
NON-NETWORK: Inpatient: 50% Coinsurance
Outpatient: 100% coinsurance; then 50% coinsurance after out-of-pocket maximum is met |
Inpatient Services
(overnight hospital/facility stays) |
NETWORK: 40% Coinsurance
NON-NETWORK: All charges except $650 per day |
Outpatient Services
(No overnight hospital/facility stays) |
NETWORK: 40% Coinsurance
Other Services: 100% of negotiated fee; then 0% coinsurance after out-of-pocket max is met
NON-NETWORK: All charges except $380 per day |
| Emergency Room Services |
NETWORK: 40% Coinsurance plus $100 Emergency Room copay (copay waived if admitted)
NON-NETWORK: 40% Coinsurance plus $100 Emergency Room copay (copay waived if admitted) |
| Preventive Care Services |
NETWORK: 0% Coinsurance, not subject to deductible
NON-NETWORK: 100% Coinsurance; then 50% Coinsurance after out-of-pocket max is met |
| Maternity |
Not Covered |
Optional Coverages
(for additional cost) |
Dental, Life |
Prescription Drugs:
Retail Drugs (and Mail Order Drugs when available) |
NETWORK:
Tier 1 (Generic Drugs): $15 Copay
$7,500 annual Prescription Drug deductible per member applies before the following:
Tier 2 (Formulary Brand name drugs): $40 Copay
Tier 3 (Non-formulary Brand name drugs): $60 Copay
Specialty: 25% Coinsurance up to $2,500 annual Prescription Drug out-of-pocket max (the most you'll have to pay),
for network only and in additional to $7,500 annual deductible.
NON-NETWORK: Not Covered |
Important Disclaimer: Answers and comments provided above
are general information, and are not intended to substitute for
informed professional medical, psychiatric, psychological, tax, legal,
investment, accounting, governmental, or other professional advice.
We do not endorse, and expressly disclaims liability for any product,
manufacturer, distributor, service, health plan, or service provider mentioned
or any opinion expressed in the website. Replies, comments, or information
gathered on HealthInsuranceAnswer.com
website may not be accurate but are intended to be helpful.