| Copay |
Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $30 copay, deductible waived (Unlimited visits); Specialist Visit: 20% after deductible (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): $30 copay, deductible waived (Unlimited visits); Specialist Visit: 20% after deductible (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: $2,500, Family: $5,000 |
Individual: $2,500, Family: $5,000 |
| Out-of-Pocket Maximum |
N/A |
N/A |
| Lifetime Maximum |
Unlimited |
Unlimited |
| Prescription Drugs |
Pharmacy Deductible (per individual): Not Applicable; Generic (Oral Contraceptives Included): $15 copay, deductible waived; Preferred Brand (Oral Contraceptives Included): Not covered; Non-Preferred Brand (Oral Contraceptives Included): Not covered; Self-Injectables: Not covered |
Pharmacy Deductible (per individual): Not Applicable; Generic (Oral Contraceptives Included): $15 copay plus 50%, deductible waived; Preferred Brand (Oral Contraceptives Included): Not covered; Non-Preferred Brand (Oral Contraceptives Included): Not covered; Self-Injectables: Not covered |
| Emergency Room |
$150 copay (waived if admitted), after deductible |
$150 copay (waived if admitted), 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): 50% after deductible; Preventive Health - Routine Physical (No waiting period): 50% after deductible (Includes lab work and X-rays) |
| 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 |
Physical/Occupational Therapy (24 visits per calendar year, maximum applies to combined in and out-of-network benefits): 20% after deductible |
Physical/Occupational Therapy (24 visits per calendar year, maximum applies to combined in and out-of-network benefits): 50% after deductible |
| Home Health Care |
20% after deductible (in lieu of hospital, 30 visits per calendar year, maximum applies to combined in and out-of-network benefits) |
50% after deductible (in lieu of hospital, 30 visits 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 |
