|
Annual Deductible/Individual
|
$0
|
|
Outpatient Specialist Visit
|
$25 Access+ Specialist: /visit; Other Specialist: $25/visit
|
|
Annual Out-of-Pocket Limit/Individual
|
$1,500
|
|
Annual Out-of-Pocket Limit/Family
|
$4,500
|
|
Inpatient Hospitalization
|
$250 /admission
|
|
Surgical Services Outpatient Facility Charge
|
$150 Ambulatory Surgery Center: /surgery; Outpatient Hospital: $150/surgery
|
|
Emergency Room
|
$150 Facility Fee: /visit; Physician Fee: 0%
|
|
Prescription Drug Deductible
|
$0
|
|
Prescription Drugs - Generic
|
$10 /prescription
|
|
Prescription Drugs - Brand (Formulary/Preferred)
|
$40 /prescription
|
|
Prescription Drugs - Brand (Non-Formulary/Non-preferred)
|
$70 /prescription
|
|
Prescription Drugs - Specialty
|
$70 /prescription
|
