|
Annual Deductible/Individual
|
$0
|
|
Annual Deductible/Family
|
$0
|
|
Coinsurance
|
0%
|
|
Office Visit/Exam
|
$30
|
|
Outpatient Specialist Visit
|
$30
|
|
Annual Out-of-Pocket Limit/Individual
|
$1,500
|
|
Annual Out-of-Pocket Limit/Family
|
$3,000 $1,500 for Each Member in a Family of two or more Members
|
|
Preventive Care
|
0%
|
|
Inpatient Hospitalization
|
$250 / admission
|
|
Surgical Services Outpatient Facility Charge
|
$30 / procedure
|
|
Emergency Room
|
$100
|
|
Urgent Care Facility
|
$30
|
|
Prescription Drug Deductible
|
$0
|
|
Prescription Drugs - Generic
|
$10
|
|
Prescription Drugs - Brand (Formulary/Preferred)
|
$25
|
|
Prescription Drugs - Brand (Non-Formulary/Non-preferred)
|
$25
|
|
Prescription Drugs - Specialty
|
20% up to $150
|
|
Chiropractic Services
|
Covered; up to 30 visit limit / year
|
|
Acupuncture
|
Covered; plan provider referred)
|
