|
Annual Deductible/Individual
|
$0
|
|
Outpatient Specialist Visit
|
$35
|
|
Annual Out-of-Pocket Limit/Individual
|
$2,500
|
|
Annual Out-of-Pocket Limit/Family
|
$5,000
|
|
Inpatient Hospitalization
|
$500 / admission
|
|
Surgical Services Outpatient Facility Charge
|
$250
|
|
Emergency Room
|
$200 ; copay waived if admitted directly to the hospital as an inpatient.
|
|
Prescription Drug Deductible
|
$0
|
|
Prescription Drugs - Generic
|
$10
|
|
Prescription Drugs - Brand (Formulary/Preferred)
|
$35
|
|
Prescription Drugs - Brand (Non-Formulary/Non-preferred)
|
$70
|
|
Prescription Drugs - Specialty
|
20% up to $250
|
|
Chiropractic Services
|
$25 ; 20 visit limit / year
|
|
Acupuncture
|
$25 ; 20 visit limit / year
|
