Typical Plan Features of an Individual Health Insurance Policy
In-Network Out-of-Network
Annual Deductible
Individual $1,000 - $ 5,000 $2,000 - $10,000
Family $2,000 - $10,000 $4,000 - $20,000
Annual Out-of-Pocket Maximum
Individual $2,000 - $ 5,000 $4,000 - $10,000
Family $4,000 - $10,000 $8,000 - $20,000
Lifetime Maximum Benefit $1,000,000 - $5,000,000
Physician Visit
General Practitioner $25-50 Co-Pay Carrier Pays 60%
Specialist $35-75 Co-Pay Carrier Pays 60%
Preventative Care (Ages 7 and Up) Co-Pay, then 100% Carrier Pays 60%
up to$300 per Insured after Deductible
per Calendar Year up to $300 per Insured
per Calendar Year
Mammogram, Pap Smears,
PSA, Etc. Carrier Pays 80% Carrier Pays 60%
after Deductible
Child Preventative care
(6 and Under) Carrier Pays 80% Carrier Pays 60%
Immunizations for Children
(6 and Under) Carrier Pays 80% Carrier Pays 60%
Ambulance Carrier Pays 80% Carrier Pays 60%
after Deductible after Deductible
Emergency Room Visits Carrier Pays 80% Carrier Pays 80%
after Deductible after Deductible
for True Emergencies,
otherwise Pays 60%
Urgent Care Facilities Carrier Pays 80% Carrier Pays 60%
after Deductible after Deductible
for True Emergencies,
otherwise Pays 60%
Inpatient Hospital Services Carrier Pays 80% Carrier Pays 60%
after Deductible after Deductible
Outpatient Surgery Carrier Pays 80% Carrier Pays 60%
after Deductible after Deductible
Outpatient Lab, X Rays,
Ultrasound, MRI and CT Scan Carrier Pays 80% Carrier Pays 60%
after Deductible after Deductible
Physical, Occupational and
Speech Therapy Carrier Pays $30 Maximum per Visit per Insured
Durable Medical Equipment Carrier Pays 80% Carrier Pays 60%
after Deductible after Deductible
Mental Health and Substance
Abuse - Inpatient Carrier Pays 80% Carrier Pays 60%
after Deductible after Deductible
Mental Health - Outpatient Carrier Pays 80% Carrier Pays 60%
after Deductible after Deductible
Prescription Drugs
Retail Pharmacy
Brand Name Deductible $100 Deductible
Generic / Brand Name /
Non Preferred Brand Name $10 / $35 / $60 Carrier Pays 50%
Self Injectables Carrier Pays 70% Carrier Pays 50%
Mail Order Pharmacy
Generic / Brand Name /
Non Preferred Brand Name $25 / $85 / $150 Not Covered
per 90 Day Supply
Self Injectables Carrier Pays 70% Not Covered