|
Annual Deductible/Individual
|
$1,000
|
$3,000
|
|
Office Visit/Exam
|
$35 deductible does not apply
|
30%
|
|
Outpatient Specialist Visit
|
$55 deductible does not apply
|
30%
|
|
Annual Out-of-Pocket Limit/Individual
|
$5,000
|
$15,000
|
|
Annual Out-of-Pocket Limit/Family
|
$10,000
|
$30,000
|
|
Preventive Care
|
0% deductible does not apply
|
30% for coverage birth through age 16; not covered for coverage age 17 and older
|
|
Inpatient Hospitalization
|
10%
|
30%
|
|
Surgical Services Outpatient Facility Charge
|
10%
|
30%
|
|
Emergency Room
|
$150 , plus 10%; copay waived if admitted
|
$150 , plus 10%; copay waived if admitted
|
|
Urgent Care Facility
|
$35 deductible does not apply
|
30%
|
|
Prescription Drug Deductible
|
$0
|
$0
|
|
Prescription Drugs - Generic
|
$20 for retail 30 days; $50 for retail 90 days; drug deductible does not apply
|
Not Covered
|
|
Prescription Drugs - Brand (Formulary/Preferred)
|
$30 for retail 30 days; $90 for retail 90 days; drug deductible does not apply
|
Not Covered
|
|
Prescription Drugs - Brand (Non-Formulary/Non-preferred)
|
$50 for retail 30 days; $150 for retail 90 days; drug deductible does not apply
|
Not Covered
|
|
Prescription Drugs - Specialty
|
$250 drug deductible does not apply
|
Not Covered
|
|
Chiropractic Services
|
$35 limited to annual max of 40 days; deductible does not apply; combined with Rehabilitation Services
|
30% limited to annual max of 40 days; combined with Rehabilitation Services
|
|
Acupuncture
|
$35 limited to 12 days; deductible does not apply
|
30% limited to 12 days
|
