|
Annual Deductible/Individual
|
$500
|
|
Annual Deductible/Family
|
$1,000
|
|
Coinsurance
|
10%
|
|
Office Visit/Exam
|
$20
|
|
Outpatient Specialist Visit
|
$30
|
|
Annual Out-of-Pocket Limit/Individual
|
$2,500
|
|
Annual Out-of-Pocket Limit/Family
|
$5,000
|
|
Preventive Care
|
0%
|
|
Inpatient Hospitalization
|
10% after deductible
|
|
Surgical Services Outpatient Facility Charge
|
10% after deductible
|
|
Emergency Room
|
10% after deductible
|
|
Urgent Care Facility
|
10% after deductible
|
|
Prescription Drug Deductible
|
none
|
|
Prescription Drugs - Generic
|
$10
|
|
Prescription Drugs - Brand (Formulary/Preferred)
|
$30
|
|
Prescription Drugs - Brand (Non-Formulary/Non-preferred)
|
$50
|
|
Prescription Drugs - Specialty
|
30% up to $100
|
|
Chiropractic Services
|
covered up to 60 visits per year combined with all other therapies
|
|
Acupuncture
|
$30 up to 20 visits per year
|
