Annual Deductible/Individual
|
$3,300
|
$3,300
|
Outpatient Specialist Visit
|
30%
|
50%
|
Annual Out-of-Pocket Limit/Individual
|
$5,000
|
$10,000
|
Annual Out-of-Pocket Limit/Family
|
$10,000
|
$20,000
|
Preventive Care
|
0% ; deductible does not apply
|
50%
|
Inpatient Hospitalization
|
30%
|
50% subject to benefit maximum $600/day
|
Surgical Services Outpatient Facility Charge
|
30%
|
50% subject to a benefit maximum of $350/day
|
Prescription Drug Deductible
|
combined with medical deductible
|
combined with medical deductible
|
Prescription Drugs - Generic
|
$10 Retail: /prescription
|
Not Covered
|
Prescription Drugs - Brand (Formulary/Preferred)
|
$30 Retail: /prescription
|
Not Covered
|
Prescription Drugs - Brand (Non-Formulary/Non-preferred)
|
$50 Retail: /prescription
|
Not Covered
|
Prescription Drugs - Specialty
|
$100 Retail and Network Specialty Pharmacies: /prescription
|
Not Covered
|
Chiropractic Services
|
30% up to 20 visits per year
|
50% up to 20 visits per year
|