| Network |
See Provider |
See Provider |
| Application |
Plan 10 Application |
Plan 10 Application |
| Brochure |
Plan 10 Brochure |
Plan 10 Brochure |
| Copay |
Primary Care Physician- $10 Per Visit. Specialty Physician- $25 Per Visit. |
Primary Care Physician- $10 Per Visit. Specialty Physician- $25 Per Visit. |
| Office Visit |
Primary Care Physician- $10 Per Visit Specialty Physician- $25 Per Visit |
Primary Care Physician- $10 Per Visit Specialty Physician- $25 Per Visit |
| Deductible |
None |
None |
| Coinsurance |
100% |
100% |
| Coinsurance Limit |
Copayment Maximum (per contract year)- $1,500 |
Copayment Maximum (per contract year)- $1,500 |
| Out-of-Pocket Maximum |
Copayment Maximum (per contract year)- $1,500 |
Copayment Maximum (per contract year)- $1,500 |
| Lifetime Maximum |
Unlimited |
Unlimited |
| Prescription Drugs |
Oral contraceptives included. Generic (30 Day Supply)- $10 Co-pay Brand Name if generic isn't available (30 Day Supply)- $20 Co-pay Brand Name if generic is available (30 Day Supply)- $20 plus difference in cost. Prescription Drug Limit- $1,200 Max./Cont. yr. Non-Formulary Drugs- $40 Co-pay. 20% self injectables up to $250. Note: Co-pays are per Prescription and Per Refill. |
Oral contraceptives included. Generic (30 Day Supply)- $10 Co-pay Brand Name if generic isn't available (30 Day Supply)- $20 Co-pay Brand Name if generic is available (30 Day Supply)- $20 plus difference in cost. Prescription Drug Limit- $1,200 Max./Cont. yr. Non-Formulary Drugs- $40 Co-pay. 20% self injectables up to $250. Note: Co-pays are per Prescription and Per Refill. |
| Emergency Room |
$100 Co-pay (Waived if Admitted) |
$100 Co-pay (Waived if Admitted) |
| Adult Preventative Care |
Wellness Visits/Exams- $10 Per Visit |
Plan 10 |
| Child Preventative Care |
Plan 10 |
Plan 10 |
| Lab / X-Ray |
Primary Care Office Visits/Radiology, Lab, EKG's- $10 Per Visit. |
Primary Care Office Visits/Radiology, Lab, EKG's- $10 Per Visit. |
| Maternity |
Optional Rider |
Optional Rider |
| Physical Therapy |
Outpatient- $25 Per Visit (60 Visits per Contract Year combined for Outpatient Physical, Speech, and Occupational Therapy) |
Outpatient- $25 Per Visit (60 Visits per Contract Year combined for Outpatient Physical, Speech, and Occupational Therapy) |
| Skilled Nursing |
Inpatient (Plan SNF's) (30 Days per Contract Year)- $50 Per Day/$250 Max. Per Admit |
Inpatient (Plan SNF's) (30 Days per Contract Year)- $50 Per Day/$250 Max. Per Admit |
| Home Health Care |
No Charge (60 visits per contract year) |
No Charge (60 visits per contract year) |
| Mental Health |
Not Covered |
Not Covered |
| Hospital Care |
Inpatient Room and Board/Ancillary services to include: Medical, Surgery and Rehabilitation- $100 Per Day/$500 Max. Per Admit (Unlimited Days). Diagnostic Services at a Hospital- $50 Per Visit. Diagnostic Services at a Freestanding Facility- $25 Per Visit. Outpatient Surgery at a Hospital- $100 Co-pay. Outpatient Surgery at an Ambulatory Surgery Center- $50 Co-pay. |
Inpatient Room and Board/Ancillary services to include: Medical, Surgery and Rehabilitation- $100 Per Day/$500 Max. Per Admit (Unlimited Days). Diagnostic Services at a Hospital- $50 Per Visit. Diagnostic Services at a Freestanding Facility- $25 Per Visit. Outpatient Surgery at a Hospital- $100 Co-pay. Outpatient Surgery at an Ambulatory Surgery Center- $50 Co-pay. |
| Optional Benefits |
Maternity Services |
Maternity Services |
