|
Annual Deductible/Individual
|
$0
|
|
Annual Deductible/Family
|
$0
|
|
Coinsurance
|
0%
|
|
Office Visit/Exam
|
$25 /visit
|
|
Outpatient Specialist Visit
|
$25 /visit
|
|
Annual Out-of-Pocket Limit/Individual
|
$1,500
|
|
Annual Out-of-Pocket Limit/Family
|
$4,500
|
|
Primary Care Physician Election Required
|
Yes
|
|
Preventive Care
|
$0
|
|
Preventive Screenings
|
$0
|
|
Well-Child Care
|
$0
|
|
Immunizations
|
$0
|
|
Well Woman Exams
|
$0
|
|
Mammograms
|
$0
|
|
Adult Periodic Exams with Preventive Tests
|
$0
|
|
Inpatient Hospitalization
|
$250 /admission
|
|
Semi-Private Room & Board; Including Services and Supplies
|
$250 /admission
|
|
Surgical Services Outpatient Facility Charge
|
$150 /surgery
|
|
Emergency Room
|
$150 for Facility Fee; Physician Fee: 0%
|
|
Urgent Care Facility
|
$25
|
|
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
|
|
Prescription Drugs - Number of Days Supply
|
30 days
|
|
Prescription Drugs Mail Order - Generic
|
$20
|
|
Prescription Drugs Mail Order - Brand (Formulary/Preferred)
|
$80
|
|
Prescription Drugs Mail Order - Brand (Non-Formulary/Non-preferred)
|
$140
|
|
Prescription Drugs - Specialty (Mail Order)
|
$140
|
|
Prescription Drugs Mail Order - Number of Days Supply
|
90 days
|
|
Durable Medical Equipment & Prosthetic Devices
|
$0
|
|
Chiropractic Services
|
$15 /visit, Up to 30 visits per Member, per Calendar Year.
|
|
Acupuncture
|
$15 /visit, Up to 30 visits per Member, per Calendar Year.
|
|
Outpatient Rehabilitative Physical Therapy
|
$25 /visit
|
