Coverage
General
Deductible	$300 per person/$600 per family maximum
Out-of-pocket limit (Includes deductible and coinsurance, excludes prescription drug coinsurance)	$2,500 per person/$5,000 per family
Lifetime maximum	Unlimited
Copays
Primary care office visit (including allergy shots)	You pay 20% coinsurance after the deductible
Specialist office visit	You pay 20% coinsurance after the deductible
Urgent care facility visit	You pay 20% coinsurance after the deductible
Emergency room	You pay 20% coinsurance after the deductible
Prescriptions (excluding fertility drugs)*
Network Benefits Only Out-of-Network Benefits Generic If you fill a prescription at a non-participating pharmacy but had access to a participating pharmacy, you will be reimbursed for the negotiated pharmacy cost minus the applicable in-network coinsurance. If you did not have access to a participating pharmacy, the in-network coinsurance will apply. Retail: up to a 30-day supply Retail: You pay $5 copay Mail: up to a 90-day supply Mail: You pay $10 copay     Formulary brand  You pay 20% coinsurance: Retail: up to a 30-day supply Retail: $25 minimum, $100 maximum Mail: up to a 90-day supply Mail: $50 minimum, $200 maximum     Non-formulary brand You pay 40% coinsurance: Retail: up to a 30-day supply Retail: $25 minimum, $100 maximum Mail: up to a 90-day supply Mail: $50 minimum, $200 maximum     Prescription out-of-pocket maximum $2,000 per member, per calendar year     Preferred home delivery for maintenance prescriptions  You pay an additional 10% coinsurance for maintenance prescriptions filled more than twice at a retail pharmacy     Generics preferred program (all medication classes except Coumadin and Synthroid) You pay the generic copay plus the cost difference between the generic and the brand name when a generic is available but not chosen
Hospital
Inpatient hospital and physician services	You pay 20% coinsurance after the deductible
Outpatient hospital surgical services	You pay 20% coinsurance after the deductible
Diagnostic X-ray/Lab Work and Therapeutic Services
Other radiology/X-ray	You pay 20% coinsurance after the deductible
Non-hospital lab work	You pay 20% coinsurance after the deductible
Hospital lab and X-ray	You pay 20% coinsurance after the deductible
CT, MRI	You pay 20% coinsurance after the deductible
Cancer and IV therapeutics	You pay 20% coinsurance after the deductible
Preventive Care
Well child	No copay
Maternity office visits (prenatal and postnatal)	You pay 20% coinsurance after the deductible
Physical exams and immunizations	No copay
Mammography	No copay
Colonoscopy	You pay 20% coinsurance
Vision care (routine exam)	No copay
Hearing care (routine exam)	No copay
Chiropractic
Chiropractic	You pay 20% coinsurance after deductible; limited to 20 visits per calendar year
Mental Health
Inpatient	You pay 20% coinsurance after the deductible
Outpatient	You pay 20% coinsurance after the deductible
Substance Abuse
Inpatient	You pay 20% coinsurance after the deductible
Outpatient	You pay 20% coinsurance after the deductible
Hospital Pre-Notification
Hospital pre-notification	Employee initiates; coverage reduced by $500 for failure to provide pre-notification
Special Services
Home medical services	You pay 20% coinsurance after the deductible, limited to 60 visits per calendar year
Skilled nursing facility	You pay 20% coinsurance after the deductible; limited to 60 days per calendar year
Hospice care	You pay 20% after the deductible; maximum benefit duration of six months
Medical equipment and supplies	You pay 20% coinsurance after the deductible; limits may apply
Physical and occupational therapy	You pay 20% coinsurance after the deductible; limited to 60 visits per calendar year
Speech therapy	You pay 20% coinsurance after the deductible; limited to 60 visits per calendar year
Transplant	You pay 20% coinsurance after the deductible; coverage based on a limited list of organs/diseases
Voluntary sterilization	You pay 20% coinsurance after the deductible
Reversal of voluntary sterilization	Not covered
Dental services	You pay 20% coinsurance after the deductible for treatment due to: a. accidental injury (treatment must occur within 12 months of the injury) b. treatment or removal of a malignant tumor c. surgery to the joint of the jaw
Infertility
Provider services	You pay 20% coinsurance after the deductible; $20,000 lifetime maximum benefits
Prescription drugs	You pay 50% coinsurance through Express Scripts Network (does not apply to out-of-pocket maximum)

Note: The information contained in this summary is for comparative purposes and does not include all benefits, limitations and exclusions.

* Specialty medicine sourced by CuraScript mail order pharmacy subject to retail prescription drug design. The prescription drugs annual out-of-pocket maximum per person includes both retail and mail order drug expenses (excluding infertility medications, which are covered at 50 percent) and is separate from the Out-of-Area Plan's annual out-of-pocket expenses. Once you pay $2,000 in prescription drug copays and coinsurance, all retail, specialty medicine and mail order prescription drugs filled during the remainder of the calendar year will be covered at 100 percent of eligible expenses. If you fill a prescription at a non-participating pharmacy but have access to a participating pharmacy, you will be reimbursed for the negotiated pharmacy cost minus the applicable copay.

* This link is accessible only to employees logged into Travelers secure network.