Individual - $1,500 annual maximum of out of pocket expenses

Family - $3,000 annual maximum of out of pocket expenses

No Cost for Hospital Visits, both inpatient and outpatient. 

Note: Except for $15/visit for physical, occupational, and speech therapy performed on an outpatient basis.

$15 per visit

No Cost

No Cost

$15 per visit

$50 per visit

Note: Waived if hospitalized as an inpatient or for observaation as an outpatient.

$15 per visit

Note: Up to 20 combined acupuncture and chiropractic visits in a calendar year.