|
Annual Deductible/Individual
|
$5,500 per Individual
|
|
Outpatient Specialist Visit
|
$50 / visit
|
|
Annual Out-of-Pocket Limit/Individual
|
$7,000 per Individual
|
|
Annual Out-of-Pocket Limit/Family
|
$14,000 per Family
|
|
Preventive Care
|
0% , deductible does not apply.
|
|
Inpatient Hospitalization
|
40% after deductible
|
|
Surgical Services Outpatient Facility Charge
|
40% ; after deductible
|
|
Prescription Drug Deductible
|
Combine with medical deductible
|
|
Prescription Drugs - Generic
|
$15 / prescription, after deductible
|
|
Prescription Drugs - Brand (Formulary/Preferred)
|
40% up to $100 / prescription, after deductible
|
|
Prescription Drugs - Brand (Non-Formulary/Non-preferred)
|
40% up to $100 / prescription, after deductible
|
|
Prescription Drugs - Specialty
|
40% up to $250 / prescription, after deductible
|
