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