| Copay |
Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $40 copay deductible waived (Unlimited visits); Specialist Visit: $50 copay deductible waived (Unlimited visits) |
Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits) |
| OfficeVisit |
Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $40 copay, deductible waived (Unlimited visits); Specialist Visit: $50 copay, deductible waived (Unlimited visits) |
Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits) |
| Deductible |
|
|
| Coinsurance |
20% after deductible up to out of pocket max ($0 once out of pocket max is satisfied) |
50% after deductible up to out of pocket max ($0 once out of pocket max is satisfied) |
| Coinsurance Limit |
Individual: $5,000, Family: $10,000 |
|
| Out-of-Pocket Maximum |
N/A |
N/A |
| Lifetime Maximum |
Unlimited |
Unlimited |
| Prescription Drugs |
Pharmacy Deductible (per individual): $500 (Does not apply to generic); Generic (Oral Contraceptives Included): $15 copay deductible waived; Preferred Brand (Oral Contraceptives Included): $35 copay after deductible; Non-Preferred Brand (Oral Contraceptives Included): $65 copay after deductible; Self-Injectible: 25% after deductible. |
Pharmacy Deductible : $500 (Does not apply to generic); Generic (Oral Contraceptives Included): $15 copay + 50% deductible waived; Preferred Brand (Oral Contraceptives Included): $35 copay plus 50% after deductible; Non-Preferred Brand Copay / Coinsurance: $65 copay plus 50% after deductible; Self-Injectible Drugs Copay / Coinsurance : Not Covered |
| Emergency Room |
$350 copay (copay waived if admitted) |
$350 copay (copay waived if admitted) |
| Adult Preventative Care |
Annual Routine Gyn Exam (No waiting period, no calendar year max. Annual Pap/Mammogram): $0 copay deductible waived; Preventive Health - Routine Physical (No waiting period): $0 copay deductible waived (Includes lab work and X-rays) |
Annual Routine Gyn Exam (No waiting period, no calendar year max. Annual Pap/Mammogram): 50% after deductible; Preventive Health - Routine Physical (No waiting period): 50% |
| Child Preventative Care |
$0 copay (Age and frequency schedule apply); No charge for immunizations up to the age of 18 |
50% after deductible (Age and frequency schedule apply); No charge for immunizations up to the age of 18 |
| Lab / X-Ray |
20% after deductible (Non-Preventive) |
50% after deductible (Non-Preventive) |
| Maternity |
Not covered (Except for pregnancy complications) |
Not covered (Except for pregnancy complications) |
| Physical Therapy |
20% after deductible (24 visits per calendar year, Maximum applies to combined in and out-of-network benefits) |
50% after deductible (24 visits per calendar year, 30 days per calendar year, Maximum applies to combined in and out-of-network benefits) |
| Home Health Care |
20% after deductible (instead of hospital 30 days per calendar year, Maximum applies to combined in and out-of-network benefits) |
50% after deductible (instead of hospital 30 days per calendar year, Maximum applies to combined in and out-of-network benefits) |
| Mental Health |
Inpatient and Outpatient: Coverage is only provided for severe, biologically based mental or nervous disorders (Deductible and coinsurance/copay apply) |
Inpatient and Outpatient: Coverage is only provided for severe, biologically based mental or nervous disorders (Deductible and coinsurance/copay apply) |
| Hospital Care |
Hospital Admission: 20% after deductible; Outpatient Surgery: 20% after deductible; Urgent Care Facility: $50 copay deductible waived |
Hospital Admission: 50% after deductible; Outpatient Surgery: 50% after deductible; Urgent Care Facility: 50% after deductible |
