|
Annual Deductible/Individual
|
$250
|
$1,000
|
|
Annual Deductible/Family
|
$500
|
$2,000
|
|
Coinsurance
|
20%
|
50%
|
|
Office Visit/Exam
|
$20
|
50% after deductible
|
|
Outpatient Specialist Visit
|
$40
|
50% after deductible
|
|
Annual Out-of-Pocket Limit/Individual
|
$3,500
|
$10,500
|
|
Annual Out-of-Pocket Limit/Family
|
$7,000
|
$21,000
|
|
Preventive Care
|
0%
|
50% after deductible
|
|
Inpatient Hospitalization
|
20% after deductible
|
50% after deductible
|
|
Surgical Services Outpatient Facility Charge
|
20% after deductible
|
50% after deductible
|
|
Emergency Room
|
20% after deductible
|
20% after deductible
|
|
Urgent Care Facility
|
$50
|
50% after deductible
|
|
Prescription Drug Deductible
|
$0
|
$0
|
|
Prescription Drugs - Generic
|
$15 copay/prescription for retail 30 days; $38 copay/prescription for retail 90 days
|
50%
|
|
Prescription Drugs - Brand (Formulary/Preferred)
|
$35 copay/prescription for retail 30 days; $88 copay/prescription for retail 90 days
|
50%
|
|
Prescription Drugs - Brand (Non-Formulary/Non-preferred)
|
$50 copay/prescription for retail 30 days; $125 copay/prescription for retail 90 days
|
50%
|
|
Prescription Drugs - Specialty
|
N/A
|
N/A
|
|
Chiropractic Services
|
$20 up to 25 visits
|
50% up to 25 visits after deductible
|
|
Acupuncture
|
covered up to 20 visits
|
not covered
|
