|
Annual Deductible/Individual
|
$2,500 Individual
|
|
Office Visit/Exam
|
$40 / visit, deductible does not apply
|
|
Outpatient Specialist Visit
|
$40 / visit, deductible does not apply
|
|
Annual Out-of-Pocket Limit/Individual
|
$5,000 Individual
|
|
Annual Out-of-Pocket Limit/Family
|
$10,000 Family
|
|
Preventive Care
|
0% , deductible does not apply
|
|
Inpatient Hospitalization
|
30% after deductible
|
|
Surgical Services Outpatient Facility Charge
|
30% 30% after deductible
|
|
Emergency Room
|
30% after deductible, copy waived if admitted
|
|
Urgent Care Facility
|
$40 / visit, deductible does not apply
|
|
Prescription Drug Deductible
|
$0
|
|
Prescription Drugs - Generic
|
$10 Retail: / prescription; deductible does not apply
|
|
Prescription Drugs - Brand (Formulary/Preferred)
|
$30 Retail: / prescription; deductible does not apply
|
|
Prescription Drugs - Brand (Non-Formulary/Non-preferred)
|
$30 Retail: / prescription; deductible does not apply
|
|
Prescription Drugs - Specialty
|
20% up to $250 / prescription, deductible does not apply
|
