| Copay |
$35 primary care/$50 specialist unlimited visits for illness or injury |
Not applicable |
| OfficeVisit |
Preventive Office Visits: 100%
Physician Office Visits (including allergy injections): 100% after office visit copayment |
Preventive Office Visits: Not covered
Physician Office Visits (including allergy injections): 60% after office visit copayment |
| Deductible |
|
|
| Coinsurance |
80% |
60% |
| Coinsurance Limit |
Individual: $2,000, Family: $4,000 (per calendar year; deductibles and copayments do not apply) |
|
| Out-of-Pocket Maximum |
N/A |
N/A |
| Lifetime Maximum |
Unlimited |
Unlimited |
| Prescription Drugs |
Rx4 Prescription Drug (medical out-of-pocket maximum does not apply) -
- Deductible per Individual: Separate $500 deductible (Level 1 drugs subject to copay, no deductible)
- Copay for each Prescription or Refill (up to a 90-day supply; with applicable copay for each 30 day supply) -
- Level 1: $15
- Level 2: $35
- Level 3: $55
- Level 4: 25%
- Copayment Maximum (applies to Level 4 drugs only): $2,500 per individual per calendar year
- Benefit per Prescription or Refill: 100% after prescription copayment
- Mail Order (up to 90-day supply): 100% after three times retail copay
|
Rx4 Prescription Drug (medical out-of-pocket maximum does not apply) -
- Deductible per Individual: Separate $500 deductible (Level 1 drugs subject to copay, no deductible)
- Copay for each Prescription or Refill (up to a 90-day supply; with applicable copay for each 30 day supply) -
- Level 1: $15
- Level 2: $35
- Level 3: $55
- Level 4: 25%
- Copayment Maximum (applies to Level 4 drugs only): $2,500 per individual per calendar year
- Benefit per Prescription or Refill: 70% after prescription copayment
- Mail Order (up to 90-day supply): 70% after three times retail copay
|
| Emergency Room |
80% after $75 copayment per visit and deductible (copayment waived if admitted) |
80% after $75 copayment per visit and deductible (copayment waived if admitted) |
| Adult Preventative Care |
Gynecological Exam, Including Pap Smear, Medically Necessary Screenings, and Non-routine Immunizations (age 13 and older): 100%
Prostate Screening: 100%
Mammograms: 100%
Preventive Office Visits (age 6 to adult): 100%
Preventive Lab (age 6 to adult): 100%
Preventive X-ray: 100% |
Gynecological Exam, Including Pap Smear, Medically Necessary Screenings, and Non-routine Immunizations (age 13 and older): 60% after deductible
Prostate Screening: 60% after deductible
Mammograms: 60% after deductible
Preventive Office Visits (age 6 to adult): Not Covered
Preventive Lab (age 6 to adult): Not Covered
Preventive X-ray: Not Covered |
| Child Preventative Care |
Child Office Visits (birth to age 6): 100%
Immunizations and Lab (when included with exam)(birth to age 6): 100%
Gynecological Exam, Including Pap Smear, Medically Necessary Screenings, and Non-routine Immunizations (age 13 and older): 100%
Preventive Office Visits (age 6 to adult): 100%
Immunizations (age 6 to 18): 100%
Pap Smear (to age 13): 100%
Preventive Lab (age 6 to adult): 100% |
Child Office Visits (birth to age 6): 100%
Immunizations and Lab (when included with exam)(birth to age 6): 100%
Gynecological Exam, Including Pap Smear, Medically Necessary Screenings, and Non-routine Immunizations (age 13 and older): 60% after deductible
Preventive Office Visits (age 6 to adult): Not Covered
Immunizations (age 6 to 18): Not Covered
Pap Smear (to age 13): Not Covered
Preventive Lab (age 6 to adult): Not Covered |
| Lab / X-Ray |
Diagnostic Lab and X-ray: First $200 per calendar year 100% then 80% after deductible |
Diagnostic Lab and X-ray: 60% after deductible |
| Maternity |
Pregnancy Complications and Sick Baby Services: 80% after deductible (prior authorization required in order to be eligible for these benefits) |
Pregnancy Complications and Sick Baby Services: 60% after deductible (prior authorization required in order to be eligible for these benefits) |
| Physical Therapy |
N/A |
N/A |
| Home Health Care |
Hospice: 80% after deductible (prior authorization required in order to be eligible for these benefits)
Home Health Care (up to 60 visits per calendar year): 80% after deductible (prior authorization required in order to be eligible for these benefits) |
Hospice: 60% after deductible (prior authorization required in order to be eligible for these benefits)
Home Health Care (up to 60 visits per calendar year): 60% after deductible (prior authorization required in order to be eligible for these benefits) |
| Mental Health |
Mental Health, Chemical and Alcohol Dependency (Medical out-of-pocket maximum does not apply) -
Inpatient Services (25 days per calendar year to age 19; 20 days per calendar year, age 19 and older): 80% after deductible
Outpatient Services (20 visits per calendar year)
- visits one through five: 80% after deductible
- visits six though 20: 50% after deductible
|
Mental Health, Chemical and Alcohol Dependency (Medical out-of-pocket maximum does not apply) -
Inpatient Services (25 days per calendar year to age 19; 20 days per calendar year, age 19 and older): 60% after deductible
Outpatient Services (20 visits per calendar year)
- visits one through five: 60% after deductible
- visits six though 20: 50% after deductible
|
| Hospital Care |
Physician Services -
- Allergy Testing: First $200 per calendar year 100% then 80% after deductible
- Allergy Serum: 80% after deductible
- Inpatient and Outpatient Services: 80% after deductible
- Surgery: 80% after deductible
Facility Services -
- Inpatient and Outpatient Services: 80% after deductible
- Outpatient Surgery: 80% after deductible
|
Physician Services -
- Allergy Testing: 60% after deductible
- Allergy Serum: 60% after deductible
- Inpatient and Outpatient Services: 60% after deductible
- Surgery: 60% after deductible
Facility Services -
- Inpatient and Outpatient Services: 60% after deductible
- Outpatient Surgery: 60% after deductible
|
