ODS Health Plan
| In Network Provider | Out of Network Provider | |
|---|---|---|
| Plan year deductible (family deductible is 2x the individual) |
$3,000 (individual) $6,000 (family) |
|
| Out-of-Pocket Maximum, Per Member (after deductible) |
$0 | No maximum |
| Plan Year Essential Benefit Maximum | $2,000,000 | |
| Preventive Care | Member Responsibility | |
| Annual women’s exam -Pap, pelvic, breast | $0* | 50% |
| Women's routine mammogram | $0* | 50% |
| Well-baby care | $0* | 50% |
| Routine Physical Exams | $0* | 50% |
| Immunizations | $0* | 50% |
| Professional Services | ||
| Office Visits | 0% | 50% |
| Alternative care ($1,000 per plan year limit) Chiropractic, naturopathic and acupuncture |
0% | 50% |
| Facility and Ancillary Services | ||
| Hospital - Inpatient and outpatient surgery; room, ancillary and physician charges; skilled nursing facility care | 0% | 50% |
| Maternity - All pre/post office visits and doctor delivery; hospital charges | 0% | 50% |
| Mental health - Inpatient, outpatient, residential (see limitations and exclusions) |
0% | 50% |
| Alcohol / Mental Health Treatment Inpatient, outpatient, residential combined |
0% | 50% |
| Lab and X-ray services; rehabilitation services; medical supplies and devices; in-hospital care; home healthcare | 0% | 50% |
| Vision (see limitations and exclusions) |
Not covered | |
| Emergency Services | ||
| Urgent care | 0% | 50% |
| Emergency room (deductible applies) | 0% | |
| Ambulance ($5,000 per plan year limit) | 0% | |
| Other Benefits | ||
| Prescription services | 0% | |
| Accident benefit | Paid as any other illness subject to deductible/coinsurance | |
| *Deductible waived | ||
