|
Annual Deductible/Individual
|
$250
|
|
Outpatient Specialist Visit
|
$10 $10 / visit
|
|
Annual Out-of-Pocket Limit/Individual
|
$2,500
|
|
Annual Out-of-Pocket Limit/Family
|
$5,000
|
|
Inpatient Hospitalization
|
10% after deductible
|
|
Surgical Services Outpatient Facility Charge
|
10% after deductible
|
|
Emergency Room
|
10% 10% after deductible, copay waived if admitted
|
|
Prescription Drug Deductible
|
$0 0
|
|
Prescription Drugs - Generic
|
$10
|
|
Prescription Drugs - Brand (Formulary/Preferred)
|
$30 $30
|
|
Prescription Drugs - Brand (Non-Formulary/Non-preferred)
|
$30 $30
|
|
Prescription Drugs - Specialty
|
-
|
