| Network |
See Provider |
See Provider |
| Application |
C20-2500 Application |
C20-2500 Application |
| Brochure |
C20-2500 Brochure |
C20-2500 Brochure |
| Copay |
Primary Care Physician- $20 Copay Specialist Office Visits- $40 Copay |
Primary Care Physician- $20 Copay Specialist Office Visits- $40 Copay |
| Office Visit |
Primary Care Physician- $20 Copay Specialist Office Visits- $40 Copay |
Primary Care Physician- $20 Copay Specialist Office Visits- $40 Copay |
| Deductible |
$2,500 |
$2,500 |
| Coinsurance |
80% |
80% |
| Coinsurance Limit |
Total Out-of-Pocket Maximum (per contract year)- $4,500 |
Total Out-of-Pocket Maximum (per contract year)- $4,500 |
| Out-of-Pocket Maximum |
Total Out-of-Pocket Maximum (per contract year)- $4,500 |
Total Out-of-Pocket Maximum (per contract year)- $4,500 |
| Lifetime Maximum |
Unlimited |
Unlimited |
| Prescription Drugs |
Pharmacy Deductible (applies to all prescription drugs)- $250. Formulary Generic Prescription Drugs- $20 Copay. Formulary Brand Name Prescription Drugs- $35 Copay. Non-formulary Prescription Drugs- $50 Copay. Self-Injectables ($250 monthly out-of-pocket maximum)- 20%. Pharmacy Maximum Benefit (per contract year)- $1,200. |
Pharmacy Deductible (applies to all prescription drugs)- $250. Formulary Generic Prescription Drugs- $20 Copay. Formulary Brand Name Prescription Drugs- $35 Copay. Non-formulary Prescription Drugs- $50 Copay. Self-Injectables ($250 monthly out-of-pocket maximum)- 20%. Pharmacy Maximum Benefit (per contract year)- $1,200. |
| Emergency Room |
Hospital Emergency Room Visit (Waived if Admitted)- $100 Copay |
Hospital Emergency Room Visit (Waived if Admitted)- $100 Copay |
| Adult Preventative Care |
Annual physical exams and well woman visits: - Primary Care Physician- $20 Copay
- Specialist Office Visits- $40 Copay
|
Well-child visits and immunizations:- Primary Care Physician- $20 Copay
- Specialist Office Visits- $40 Copay
|
| Child Preventative Care |
Well-child visits and immunizations:- Primary Care Physician- $20 Copay
- Specialist Office Visits- $40 Copay
|
Well-child visits and immunizations:- Primary Care Physician- $20 Copay
- Specialist Office Visits- $40 Copay
|
| Lab / X-Ray |
Routine lab tests and diagnostic procedures and radiology:- Primary Care Physician- $20 Copay
- Specialist Office Visits- $40 Copay
|
Routine lab tests and diagnostic procedures and radiology:- Primary Care Physician- $20 Copay
- Specialist Office Visits- $40 Copay
|
| Maternity |
Optional Rider |
Optional Rider |
| Physical Therapy |
Outpatient Physical, Speech and Occupational Therapy at a Freestanding Facility (60 visits per contract year, combined for all therapy types)- $40 Copay. Outpatient Physical, Speech and Occupational Therapy at a Hospital (60 visits per contract year, combined for all therapy types)- 80% Coinsurance after Hospital Deductible. |
Outpatient Physical, Speech and Occupational Therapy at a Freestanding Facility (60 visits per contract year, combined for all therapy types)- $40 Copay. Outpatient Physical, Speech and Occupational Therapy at a Hospital (60 visits per contract year, combined for all therapy types)- 80% Coinsurance after Hospital Deductible. |
| Skilled Nursing |
$100 per days 1-5 (30 days per contract year) |
$100 per days 1-5 (30 days per contract year) |
| Home Health Care |
No Copay (60 visits per contract year) |
No Copay (60 visits per contract year) |
| Mental Health |
Not Covered |
Not Covered |
| Hospital Care |
Inpatient Hospital Facility and Physician Services- 80% Coinsurance after Hospital Deductible. Outpatient Diagnostic Services at a Hospital- 80% Coinsurance after Hospital Deductible. Outpatient Surgery at a Hospital- 80% Coinsurance after Hospital Deductible. |
Inpatient Hospital Facility and Physician Services- 80% Coinsurance after Hospital Deductible. Outpatient Diagnostic Services at a Hospital- 80% Coinsurance after Hospital Deductible. Outpatient Surgery at a Hospital- 80% Coinsurance after Hospital Deductible. |
| Optional Benefits |
C20-2500 |
C20-2500 |
