| Copay |
$40 with preferred providers |
Not applicable with non-preferred providers |
| OfficeVisit |
Office Visits (first 3 visits/calendar year - subsequent visits are subject to the deductible): $40 (No charge after deductible) |
Office Visits (first 3 visits/calendar year - subsequent visits are subject to the deductible): 50% |
| Deductible |
|
|
| Coinsurance |
100% |
50% |
| Coinsurance Limit |
Services with preferred providers: $3,000 |
|
| Out-of-Pocket Maximum |
|
|
| Lifetime Maximum |
No Limit |
No Limit |
| Prescription Drugs |
At Participating Pharmacies (up to a 30-day supply):- Generic formulary drugs: $10/prescription
- Formulary brand-name drugs: Not covered
- Non-formulary brand-name drugs: Not covered
Mail Service Prescriptions (up to a 60-day supply):- Generic formulary drugs: $20/prescription
- Formulary brand-name drugs: Not covered
- Non-formulary brand-name drugs: Not covered
|
At Participating Pharmacies (up to a 30-day supply):- Generic formulary drugs: $10/prescription
- Formulary brand-name drugs: Not covered
- Non-formulary brand-name drugs: Not covered
Mail Service Prescriptions (up to a 60-day supply):- Generic formulary drugs: $20/prescription
- Formulary brand-name drugs: Not covered
- Non-formulary brand-name drugs: Not covered
|
| Emergency Room |
Emergency Health Coverage:- Emergency room service ($100 copayment/visit waived if the member is admitted directly to the hospital as an inpatient): $100/visit
- ER physician visits: No charge after deductible
- Ambulance services (surface or air): No charge after deductible
|
Emergency Health Coverage:- Emergency room service ($100 copayment/visit waived if the member is admitted directly to the hospital as an inpatient): $100/visit
- ER physician visits: No charge after deductible
- Ambulance services (surface or air): No charge after deductible
|
| Adult Preventative Care |
Annual routine physical exam and gynecological exam office visit (includes Pap test of other approved cervical cancer screening tests, routine mammography, and immunizations when received as part of the annual exam or preventive care visit): $40 |
Annual routine physical exam and gynecological exam office visit (includes Pap test of other approved cervical cancer screening tests, routine mammography, and immunizations when received as part of the annual exam or preventive care visit): Not covered |
| Child Preventative Care |
Annual routine physical exam and well-baby care office visits: $40 |
Annual routine physical exam and well-baby care office visits: Not covered |
| Lab / X-Ray |
Outpatient or out-of-hospital X-ray and laboratory: No charge after deductible |
Outpatient or out-of-hospital X-ray and laboratory: 50% |
| Maternity |
Pregnancy and Maternity Care:- Outpatient prenatal and postnatal care: Not covered
- Delivery and all necessary inpatient hospital services: Not covered
|
Pregnancy and Maternity Care:- Outpatient prenatal and postnatal care: Not covered
- Delivery and all necessary inpatient hospital services: Not covered
|
| Physical Therapy |
Rehabilitation Services: (up to 15 visits per calendar year combined with speech therapy visits):- Provided in the office of a physician or physical therapist: No charge after deductible
Chiropractic Services: Not covered |
Rehabilitation Services: (up to 15 visits per calendar year combined with speech therapy visits):- Provided in the office of a physician or physical therapist: 50%
Chiropractic Services: Not covered |
| Home Health Care |
Home Health Services (up to 60 pre-authorized visits per calendar year): No charge after deductible |
Home Health Services (up to 60 pre-authorized visits per calendar year): Not covered |
| Mental Health |
Mental Health Services:- Inpatient hospital facility services: No charge after deductible
- Inpatient physician services: No charge after deductible
- Outpatient visits for severe mental health conditions (first 3 visits/calendar year - subsequent visits subject to the deductible): $40 no charge after deductible
- Outpatient visits for non-severe mental health conditions (up to 20 visits per calendar year combined with chemical dependency visits): No charge after deductible
Chemical Dependency Services (substance abuse):- Inpatient hospital facility services for medical acute detoxification: No charge after deductible
- Inpatient physician services for medical acute detoxification: No charge after deductible
- Outpatient visits (up to 20 visits per calendar year combined with non-severe mental health visits): No charge after deductible
|
Mental Health Services:- Inpatient hospital facility services: 50%
- Inpatient physician services: 50%
- Outpatient visits for severe mental health conditions (first 3 visits/calendar year - subsequent visits subject to the deductible) 50%
- Outpatient visits for non-severe mental health conditions (up to 20 visits per calendar year combined with chemical dependency visits): Not covered
Chemical Dependency Services (substance abuse):- Inpatient hospital facility services for medical acute detoxification: 50%
- Inpatient physician services for medical acute detoxification: 50%
- Outpatient visits (up to 20 visits per calendar year combined with non-severe mental health visits): Not covered
|
| Hospital Care |
Hospitalization Services:- Inpatient physician visits and consultations, surgeons and assistants, and anesthesiologists: No charge after deductible
- Inpatient semiprivate room and board, services and supplies, and subacute care: No charge after deductible
- Bariatric surgery inpatient services (pre-authorization required: medically necessary surgery for weight loss, only for morbid obesity): No charge after deductible
Outpatient Services:- Non-emergency services and procedures: No charge after deductible
- Outpatient surgery in hospital: No charge after deductible
- Outpatient surgery performed in an ambulatory surgery center (ASC): No charge after deductible
|
Hospitalization Services:- Inpatient physician visits and consultations, surgeons and assistants, and anesthesiologists: 50%
- Inpatient semiprivate room and board, services and supplies, and subacute care: 50%
- Bariatric surgery inpatient services (pre-authorization required: medically necessary surgery for weight loss, only for morbid obesity): 50%
Outpatient services:- Non-emergency services and procedures: 50%
- Outpatient surgery in hospital: 50%
- Outpatient surgery performed in an ambulatory surgery center (ASC): 50%
|
