Page 6 - 2018 CareHere Enrollment OOS
P. 6
2018 Benefits Enrollment
Plan Details*
BCBST
Calendar Year Deductible
Individual $2,600
Family $5,000
Out-of-Pocket Maximum
Individual $4,000
Family $8,000
Physician Ofice Visits
Wellness/Preventive Covered at 100%
Primary Care 20% after deductible
Specialist 20% after deductible
Urgent Care 20% after deductible
Chiropractice Care—30 Visits 20% after deductible
Hospital Services
Inpatient 20% after deductible
Outpatient 20% after deductible
Emergency Room 20% after deductible
* In-network beneits are shown here. For out-of-network coverage details, please refer to your
summary plan description (SPD) or an oficial plan document.
6
Plan Details*
BCBST
Calendar Year Deductible
Individual $2,600
Family $5,000
Out-of-Pocket Maximum
Individual $4,000
Family $8,000
Physician Ofice Visits
Wellness/Preventive Covered at 100%
Primary Care 20% after deductible
Specialist 20% after deductible
Urgent Care 20% after deductible
Chiropractice Care—30 Visits 20% after deductible
Hospital Services
Inpatient 20% after deductible
Outpatient 20% after deductible
Emergency Room 20% after deductible
* In-network beneits are shown here. For out-of-network coverage details, please refer to your
summary plan description (SPD) or an oficial plan document.
6
