| Copay |
$40 |
$0 after copay maximum |
| OfficeVisit |
Office visits (One visit per calendar year - subsequent visits are subject to the copayment maximum): $40 |
Office visits (One visit per calendar year - subsequent visits are subject to the copayment maximum): $0 after copay maximum |
| Deductible |
|
|
| Coinsurance |
40% with preferred providers |
50% with non-preferred providers |
| Coinsurance Limit |
Services with preferred providers: $4,900 |
|
| Out-of-Pocket Maximum |
N/A |
N/A |
| 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 services ($100 copayment/visit waived if member is admitted directly to the hospital as an inpatient): $100/visit + 40%
- ER physician visits: 40%
- Ambulance services (surface or air): 40%
|
Emergency Health Coverage:- Emergency room services ($100 copayment/visit waived if member is admitted directly to the hospital as an inpatient): $100/visit + 40%
- ER physician visits: 40%
- Ambulance services (surface or air): 40%
|
| Adult Preventative Care |
Preventive Care:- Annual routine physical exam and gynecological exam office visit: $0
- Annual Pap test or other approved cervical cancer screening tests, routine mammography, and immunizations when received as part of the annual exam or preventive care visit: $0
|
Preventive Care:- Annual routine physical exam and gynecological exam office visit: Not covered
- Annual Pap test or 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 |
Preventive Care:- Annual routine physical exam and well baby care office visits: $0
- Annual immunizations when received as part of the annual exam or preventive care visit: 40%
|
Preventive Care:- Annual routine physical exam and well baby care office visits: Not covered
- Annual immunizations when received as part of the annual exam or preventive care visit: Not covered
|
| Lab / X-Ray |
Outpatient or out-of-hospital X-ray and laboratory: $0 after copay maximum |
Outpatient or out-of-hospital X-ray and laboratory: $0 after copay maximum |
| Maternity |
Pregnancy and Maternity Care:- Outpatient prenatal and postnatal care: Not covered
- Delivery and all necessary inpatient hospital services: Not covered
Family Planning:- Consultations, tubal ligation, vasectomy, elective services: $0 after copay maximum
|
Pregnancy and Maternity Care:- Outpatient prenatal and postnatal care: Not covered
- Delivery and all necessary inpatient hospital services: Not covered
Family Planning:- Consultations, tubal ligation, vasectomy, elective services: not covered
|
| Physical Therapy |
Provided in the office of a physician or physical therapist: Not covered |
Provided in the office of a physician or physical therapist: Not covered |
| Home Health Care |
Home Health Services (up to 90 pre-authorized visits per calendar year): $0 after copay maximum |
Home Health Services (up to 90 pre-authorized visits per calendar year): Not covered |
| Mental Health |
Mental Health Services:- Inpatient hospital facility services: 40%
- Inpatient physician services: 40%
- Outpatient visits for severe mental health conditions: 40%
- Outpatient visits for non-severe mental health conditions: Not covered
Chemical Dependency Services (substance abuse):- Inpatient hospital facility services for medical acute detoxification: 40%
- Inpatient physician services for medical acute detoxification: 40%
- Outpatient visits: Not covered
|
Mental Health Services:- Inpatient hospital facility services: 50% up to $500 per day
- Inpatient physician services: 50%
- Outpatient visits for severe mental health conditions: 50% up to $500 per day
- Outpatient visits for non-severe mental health conditions: 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: Not covered
|
| Hospital Care |
Hospitalization Services:- Inpatient physician visits and consultations, surgeons and assistants, and anesthesiologists: 40%
- Inpatient semiprivate room and board, services and supplies, and subacute care: 40%
- Bariatric surgery inpatient services (pre-authorization required: medically necessary surgery for weight loss, only for morbid obesity): 40%
Outpatient Services:- Non-emergency services and procedures, outpatient surgery in hospital: 40%
- Outpatient surgery performed in an ambulatory surgery center (ASC): 40%
|
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, outpatient surgery in hospital: 50%
- Outpatient surgery performed in an ambulatory surgery center (ASC): 50%
|
