|
Annual Deductible/Individual
|
$500
|
|
Office Visit/Exam
|
$25 deductible does not apply
|
|
Outpatient Specialist Visit
|
$35 deductible does not apply
|
|
Annual Out-of-Pocket Limit/Individual
|
$1,500
|
|
Annual Out-of-Pocket Limit/Family
|
$4,500
|
|
Preventive Care
|
0% ; deductible does not apply
|
|
Inpatient Hospitalization
|
$250 /admission
|
|
Surgical Services Outpatient Facility Charge
|
$150 /surgery
|
|
Emergency Room
|
$150 for Facility Fee; Physician Fee: 0%; deductible does not apply
|
|
Urgent Care Facility
|
$25 deductible does not apply
|
|
Prescription Drug Deductible
|
$0
|
|
Prescription Drugs - Generic
|
$10
|
|
Prescription Drugs - Brand (Formulary/Preferred)
|
$40
|
|
Prescription Drugs - Brand (Non-Formulary/Non-preferred)
|
$70
|
|
Prescription Drugs - Specialty
|
$70
|
|
Chiropractic Services
|
$25 up to 20 visits per Member, per Calendar year
|
|
Acupuncture
|
$25 up to 12 visits per Member, per Calendar Year
|
