hana_guide
COMPANY LOGO
BENEFIT
IN-NETWORK
OUT-OF-NETWORK
Annual Deductible
Individual: $000; Family: $000
Out-of-Pocket Maximum
Individual: $000 Family: $000
Individual: $000 Family: $000
Lifetime Maximum
$000
Preventive Care Adult Preventive Care Adult Annual Physical Exam Well-Child Care
000% 000% 000%
000% 000% 000%
Outpatient Care Primary care physician office visits Specialist office visits Outpatient facility surgery Outpatient Lab & X-Ray Initial visit, and all subsequent visits Emergency Care Ambulance when medically necessary At hospital emergency room Urgent Care Maternity Care Prenatal and Post-natal care Hospital services for mother and child
$00 $00 $00
00%* 00%* 00%*
00%
00%*
$00 $00 $00
$00* $00* $00*
000%* 000%*
000%* 00%*
Mental Health Inpatient Outpatient
000%* 000%*
00%* 00%*
Prescription Drugs Retail Pharmacy (30 day supply) Generic/Preferred Brand/Non-Preferred Brand Mail Order (30 day supply) Generic/Preferred Brand/Non-Preferred Brand
$00/$00/$00
$00/$00/$00
$00/$00/$00
$00/$00/$00
Bi-Weekly Contributions Employee Only
$00.00 $00.00 $00.00 $00.00
$00.00 $00.00 $00.00 $00.00
Employee + Spouse Employee + Children Employee + Family
* after deductible
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