Annual Deductible
$500/person/calendar year
$1,500/family/calendar year
Coinsurance
Preferred covered provider—80%
Non-preferred covered provider—50% of UCR charges
Other covered charges —80% of UCR charges
Prescription Drug Maximum
$2,500/person/calendar year
Out of Pocket Maximum
$10,500/person/calendar year
$31,500/family/calendar year
Lifetime Maximum
$1,000,000/person
With this plan, covered services are available from any covered provider. However, if you use a Preferred Provider from the First Choice network, your benefits will be greater. All services provided by non-preferred providers are subject to Usual, Customary and Reasonable (UCR) charges.
