|
Annual Deductible/Individual
|
$1,600 $3200 for any one member within a family enrollment
|
|
Annual Deductible/Family
|
$3,200
|
|
Coinsurance
|
0%
|
|
Office Visit/Exam
|
$20 after deductible
|
|
Outpatient Specialist Visit
|
$20 after deductible
|
|
Annual Out-of-Pocket Limit/Individual
|
$3,200 $3200 for any one member within a family enrollment
|
|
Annual Out-of-Pocket Limit/Family
|
$6,400
|
|
Preventive Care
|
0%
|
|
Inpatient Hospitalization
|
$250 /admission after deductible
|
|
Surgical Services Outpatient Facility Charge
|
$150 /procedure after deductible
|
|
Emergency Room
|
$100 after deductible
|
|
Urgent Care Facility
|
$20 after deductible
|
|
Prescription Drug Deductible
|
combined with medical deductible
|
|
Prescription Drugs - Generic
|
$10 after deductible
|
|
Prescription Drugs - Brand (Formulary/Preferred)
|
$30 after deductible
|
|
Prescription Drugs - Brand (Non-Formulary/Non-preferred)
|
$30 after deductible
|
|
Prescription Drugs - Specialty
|
30% up to $100 after deductible
|
|
Chiropractic Services
|
Covered up to 20 visits per year
|
|
Acupuncture
|
Covered(plan provider referred)
|
