|
Annual Deductible/Individual
|
$5,500
|
|
Outpatient Specialist Visit
|
$50 $50 / visit
|
|
Annual Out-of-Pocket Limit/Individual
|
$7,000
|
|
Annual Out-of-Pocket Limit/Family
|
$14,000
|
|
Inpatient Hospitalization
|
60% after deductible
|
|
Surgical Services Outpatient Facility Charge
|
60% after deductible
|
|
Emergency Room
|
60% 60% after deductible, copay waived if admitted
|
|
Prescription Drug Deductible
|
N/A
|
|
Prescription Drugs - Generic
|
$15
|
|
Prescription Drugs - Brand (Formulary/Preferred)
|
60%
|
|
Prescription Drugs - Brand (Non-Formulary/Non-preferred)
|
60%
|
|
Prescription Drugs - Specialty
|
-
|
