|
Annual Deductible/Individual
|
$500 for participating providers
|
|
Annual Deductible/Family
|
$1,000 for participating providers
|
|
Coinsurance
|
0%
|
|
Office Visit/Exam
|
$25 /visit; deductible does not apply
|
|
Outpatient Specialist Visit
|
$35 /visit; deductible does not apply
|
|
Annual Out-of-Pocket Limit/Individual
|
$1,500 for participating providers
|
|
Annual Out-of-Pocket Limit/Family
|
$4,500 for participating providers
|
|
Preventive Care
|
0% ; deductible does not apply
|
|
Inpatient Hospitalization
|
$250 /admission
|
|
Surgical Services Outpatient Facility Charge
|
$150 /surgery
|
|
Emergency Room
|
$150 Facility Fee: /visit; Physician Fee: 0%; deductible does not apply
|
|
Urgent Care Facility
|
$25 /visit; deductible does not apply
|
|
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
|
|
Chiropractic Services
|
$25 Up to 20 visits per Member, per Calendar year
|
|
Acupuncture
|
$25 Up to 12 visits per Member, per Calendar Year.
|
