Begin Primary Care Deductible Coinsurance After Number Of Copays
0
Inpatient Copayment Maximum Days
0
Medical Drug Deductibles Integrated
Yes
Medical Drug Maximum Out of Pocket Integrated
Yes
SBC Scenario, Having a Baby, Coinsurance
$0
SBC Scenario, Having a Baby, Copayment
$80
SBC Scenario, Having a Baby, Deductible
$8,700
SBC Scenario, Having Diabetes, Coinsurance
$0
SBC Scenario, Having Diabetes, Copayment
$1,200
SBC Scenario, Having Diabetes, Deductible
$3,500
SBC Scenario, Treatment of a Simple Fracture, Coinsurance
$0
SBC Scenario, Treatment of a Simple Fracture, Copayment
$10
SBC Scenario, Treatment of a Simple Fracture, Deductible
$2,800
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group
per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person
per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual
Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance
30.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance
30.00%
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group
$17500 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person
$8750 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual
$8,750
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group
$17500 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person
$8750 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual
$8,750
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group
per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person
per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual
Not Applicable