| Deductibles: |
- $400 individual (union)
- $500 individual (nonunion)
- Applies only to eligible dependent children living outside the service area
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| Annual OOP Max: |
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| Lifetime Max: |
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| Coinsurance: |
- 20% certain services
- 20% all services received by eligible dependent children living outside the service area
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| Preventive Care: |
- 100%
- No copay required
- Not subject to deductible
|
| Office Visits: |
- 100% after $10 copay
- Not subject to deductible
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| Diagnostic x-ray and Laboratory Services: |
- 100%
- Not subject to deductible
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| Hospital Services: |
- 100%
- Not subject to deductible
|
| Emergency Room: |
- 100% after $50 copay
- Not subject to deductible
- Emergency room treatment is paid at the network level when the condition meets the definition of a medical emergency. Refer to the Guide to Benefits below for more information.
|
| Mental Health: |
- Inpatient: 100% (not subject to deductible)
- Outpatient: 100% after $10 copay (not subject to deductible)
- Visit limitations may apply. Refer to Benefit Summary below.
- To receive benefits for mental health treatment, you must contact the Boeing Helpline (ValueOptions) at 1 (800) 892-1411.
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| Substance Abuse: |
- Inpatient: 100% (not subject to deductible)
- Outpatient: 100% after $10 copay (not subject to deductible)
- To receive benefits for substance abuse treatment, you must contact the Boeing Helpline (ValueOptions) at 1 (800) 892-1411.
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| Alternative care: |
- 100% after $10 copay. Not subject to deductible.
- Limited to a combined total of 26 spinal and extremity manipulation visits per benefit year.
- Limited 12 acupuncture visits per benefit year.
- Alternative care includes services received by acupuncturists, chiropractors, massage therapists, naturopaths, and nutritionists.
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| Prescriptions: |
- Generic: $5 retail copay; $10 mail-order copay
- Brand-name formulary: $15 retail copay; $30 mail-order copay
- Non-formulary: $30 retail copay; $60 mail-order copay
- Not subject to deductible
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| Vision: |
- 100% after $10 copay. One exam per benefit year.
- Two pairs of lenses and frames, or contact lenses every two benefit years
- Not subject to deductible
|