| TYPE OF SERVICE | NETWORK | NON-NETWORK |
| Deductible (individual / family) | $600/3 per family | $1,200/3 per family |
| Annual out-of-pocket max individual / family (excl. deductible)[1] | $5,500/3 per family | $11,000/3 per family |
| Primary Care Physician Specialist | $25$45 | 60% after deductible60% after deductible |
| Inpatient Hospital | $350 co-pay/admission, then 80% after deductible | $700 co-pay/admission, then 60% after deductible |
| Outpatient Surgery - facility charges | $250 co-pay, then 80% after deductible | $500 co-pay, then 60% after deductible |
| Outpatient Surgery - doctor’s office | 80% after deductible | 60% after deductible |
| Maternity Care Inpatient |
$350/stay co-pay, then 80% after deductible |
$700/stay co-pay, then 60% after deductible |
| First Office Visit | $45 co-pay, then 100% | 60% after deductible |
| Other Maternity | 80% after deductible | 60% after deductible |
| Ambulance | 80% after deductible | 80% after deductible |
| Emergency Room | $150, then 80% after deductible | $150, then 80% after deductible |
| Urgent Care | $45 | 60% after deductible |
| Preventive Care and Routine Well Care[2] | $25 copay, then plan pays 100% up to $500 calendar year maximum | 60% after deductible |
| Non-Preventative Lab and X-Ray | 80% after deductible | 60% after deductible |
| Physical Therapy (Outpatient) / Visit | 80% after deductible (60 visits) | 60% after deductible (60 visits) |
| Chiropractic Care / Visit (Annual Max Visits) | $45 (20 visits) | 60% after deductible (20 visits) |
| Hearing Aids / (Lifetime Max) | 80% after deductible ($800 lifetime max) | 60% after deductible ($800 lifetime max) |
| Mental Health
Inpatient |
$350 co-pay/admission, then 80% after deductible |
$700 co-pay/admission, then 60% after deductible |
| Outpatient | 80% after deductible | 60% after deductible |
| Substance Abuse Inpatient | $350 co-pay/admission, then 80% after deductible | $700 co-pay/admission, then 60% after deductible |
| Outpatient | 80% after deductible | 60% after deductible |
| Lifetime Max | $2,000,000 combined benefit for all ACS-sponsored medical plans, excluding HMOs | |
[1] The out-of-pocket maximum does not include the annual deductible, copays, non-covered expenses, expenses over reasonable and customary/negotiated fees, penalties for failing to precertify when required, chiropractic charges, or your share of the cost for treatment of mental illness and substance abuse.
[2] There is no maximum benefit for well baby care up to age two or colonoscopies. In addition, colonoscopies performed by network providers and at network facilities are covered at 80% with no deductible for any diagnosis.