|
Annual Deductible/Individual
|
$4,000
|
|
Office Visit/Exam
|
$30 Extra site: $15/visit
|
|
Outpatient Specialist Visit
|
$60
|
|
Annual Out-of-Pocket Limit/Individual
|
$9,450
|
|
Annual Out-of-Pocket Limit/Family
|
$18,900
|
|
Inpatient Hospitalization
|
30% after deductible
|
|
Surgical Services Outpatient Facility Charge
|
30% after deductible
|
|
Emergency Room
|
$200 Copay waived if admitted
|
|
Prescription Drug Deductible
|
$0
|
|
Prescription Drugs - Generic
|
$20
|
|
Prescription Drugs - Brand (Formulary/Preferred)
|
$50
|
|
Prescription Drugs - Brand (Non-Formulary/Non-preferred)
|
$90
|
|
Prescription Drugs - Specialty
|
Copayment varies by drug based on above
|
|
Chiropractic Services
|
$30 up to 15 visits per year
|
