| Copay |
Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 0% after deductible; Specialist Visit: 0% after deductible |
Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 20% after deductible; Specialist Visit: 20% after deductible |
| OfficeVisit |
Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 0% after deductible; Specialist Visit: 0% after deductible |
Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 20% after deductible; Specialist Visit: 20% after deductible |
| Deductible |
|
|
| Coinsurance |
0% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied) |
20% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied) |
| Coinsurance Limit |
Individual: $0, Family: $0 |
|
| Out-of-Pocket Maximum |
N/A |
N/A |
| Lifetime Maximum |
Unlimited |
Unlimited |
| Prescription Drugs |
Pharmacy Deductible (per individual): Integrated Medical/Rx Deductible; Generic (Oral Contraceptives Included): 0% after Medical/Rx Deductible; Preferred Brand (Oral Contraceptives Included): 0% after Medical/Rx Deductible; Non-Preferred Brand (Oral Contraceptives Included): 0% after Medical/Rx Deductible |
Pharmacy Deductible (per individual): Integrated Medical/Rx Deductible; Generic (Oral Contraceptives Included): 20% after Medical/Rx Deductible; Preferred Brand (Oral Contraceptives Included): 20% after Medical/Rx Deductible; Non-Preferred Brand (Oral Contraceptives Included): 20% after Medical/Rx Deductible |
| Emergency Room |
$0 copay after deductible |
$0 copay after deductible |
| 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): 20% after deductible; Preventive Health - Routine Physical (No waiting period): 20% coinsurance after deductible (Includes lab work and X-rays) |
| Child Preventative Care |
0% after deductible (Age limitations apply); No charge for immunizations up to the age of 18 |
20% after deductible (Age limitations apply); No charge for immunizations up to the age of 18 |
| Lab / X-Ray |
0% after deductible (Non-Preventive) |
20% after deductible (Non-Preventive) |
| Maternity |
Maternity (Inpatient Facility Services): 0% Inpatient Facility Services coverage after deductible for the mother and the newborn for a minimum of 48 hours for an uncomplicated vaginal delivery and 96 hours for an uncomplicated cesarean birth; Maternity (Professional Services): Coverage for complications of pregnancy |
Maternity (Inpatient Facility Services): 20% Inpatient Facility Services coverage after deductible for the mother and the newborn for a minimum of 48 hours for an uncomplicated vaginal delivery and 96 hours for an uncomplicated cesarean birth; Maternity (Professional Services): Coverage for complications of pregnancy |
| Physical Therapy |
Physical/Occupational Therapy (24 visits per calendar year, maximum applies to combined in and out-of-network benefits): 0% after deductible |
Physical/Occupational Therapy (24 visits per calendar year, maximum applies to combined in and out-of-network benefits): 20% after deductible |
| Home Health Care |
0% after deductible (instead of hospital, 40 visits per calendar year, Maximum applies to combined in and out-of-network benefits) |
20% after deductible (instead of hospital, 40 visits per calendar year, Maximum applies to combined in and out-of-network benefits) |
| Mental Health |
Inpatient and Outpatient: Coverage is provided for treatment of mental illness (Deductible and coinsurance/copay apply - Day and/or visit limits apply) |
Inpatient and Outpatient: Coverage is provided for treatment of mental illness (Deductible and coinsurance/copay apply - Day and/or visit limits apply) |
| Hospital Care |
Hospital Admission (Includes complications of pregnancy): 0% after deductible; Outpatient Surgery: 0% after deductible; Urgent Care Facility: 0% after deductible |
Hospital Admission (Includes complications of pregnancy): 20% after deductible; Outpatient Surgery: 20% after deductible; Urgent Care Facility: 20% after deductible |
