|
Annual Deductible/Individual
|
$750
|
|
Annual Deductible/Family
|
$1,500
|
|
Coinsurance
|
20%
|
|
Annual Out-of-Pocket Limit/Individual
|
$3,000
|
|
Annual Out-of-Pocket Limit/Family
|
$6,000
|
|
Office Visit/Exam
|
$25 /visit, deductible does not apply
|
|
Preventive Care
|
0% deductible does not apply
|
|
Preventive Screenings
|
0% deductible does not apply
|
|
Well-Child Care
|
0% deductible does not apply
|
|
Well Woman Exams
|
0% deductible does not apply
|
|
Immunizations
|
0% deductible does not apply
|
|
Mammograms
|
0% deductible does not apply
|
|
Adult Periodic Exams with Preventive Tests
|
0% deductible does not apply
|
|
Outpatient Specialist Visit
|
$25 /visit, deductible does not apply
|
|
Urgent Care Facility
|
$25 /visit, deductible does not apply
|
|
Emergency Room
|
20%
|
|
Inpatient Hospitalization
|
20%
|
|
Semi-Private Room & Board; Including Services and Supplies
|
20%
|
|
Surgical Services Outpatient Facility Charge
|
20%
|
|
Chiropractic Services
|
$25 ; 30 visit limit / year combined with acupuncture
|
|
Acupuncture
|
$25 ; 30 visit limit / year combined with chiropractic
|
|
Outpatient Rehabilitative Physical Therapy
|
$25 deductible does not apply
|
|
Durable Medical Equipment & Prosthetic Devices
|
20% for DME; Prosthetic Devices: 0%; deductible does not apply
|
|
Primary Care Physician Election Required
|
Yes
|
|
Prescription Drug Deductible
|
$0
|
|
Prescription Drugs - Generic
|
$10 deductible does not apply
|
|
Prescription Drugs - Brand (Formulary/Preferred)
|
$30 deductible does not apply
|
|
Prescription Drugs - Brand (Non-Formulary/Non-preferred)
|
$30 deductible does not apply
|
|
Prescription Drugs - Specialty
|
20% up to $200 deductible does not apply
|
|
Prescription Drugs - Number of Days Supply
|
30 days
|
|
Prescription Drugs Mail Order - Generic
|
$20 deductible does not apply
|
|
Prescription Drugs Mail Order - Brand (Formulary/Preferred)
|
$60 deductible does not apply
|
|
Prescription Drugs Mail Order - Brand (Non-Formulary/Non-preferred)
|
$60 deductible does not apply
|
|
Prescription Drugs - Specialty (Mail Order)
|
Not Covered
|
|
Prescription Drugs Mail Order - Number of Days Supply
|
100 days
|
