| Deductible (Calendar Year) | $2,000 individual/$4,000 family |
| Co-Payment Maximum (Calendar Year) | $5,000 individual/$10,000 family |
| Office visits | $30 |
| Chiropractic Services | 20% of up to $50 |
| Diagnostic Testing | 20% |
| Preventive Health Benefits | No Charge |
| Outpatient X-ray, pathology and laboratory | No Charge |
| Outpatient Services | 20% |
| Hospitalization Services | 20% |
| Skilled Nursing Facility | 20% |