|
|
| Benefits Summary |
| Annual deductible |
$2,700 |
| Annual out-of-pocket maximum |
$5,250 |
| Preventive care |
| Immunizations |
No charge |
| Routine physical exam |
No charge |
| Well-child visit (0-23 months) |
No charge |
| Well-woman visit |
No charge |
| Mammogram screening |
No charge |
| Outpatient services |
| Primary care/Specialty office visit (per visit) |
$30 copay (after deductible) |
| Most X-rays and lab tests (per procedure) |
$10 copay (after deductible) |
| MRI, CT, and PET (per procedure) |
$50 copay (after deductible) |
| Outpatient surgery (per procedure) |
30% coinsurance (after deductible) |
| Inpatient hospital care |
| Room and board, surgery, anesthesia, X-rays, lab tests,and medications |
30% coinsurance (after deductible) |
| Maternity (Coverage varies) |
| Routine prenatal care visit |
No charge |
| Delivery and inpatient well-baby care |
30% coinsurance (after deductible) |
| Emergency and urgent care |
| Emergency Department visit (waived if admitted) |
30% coinsurance (after deductible) |
| Urgent care visit |
$30 copay (after deductible) |
| Ambulance service |
$100 copay (after deductible) |
| Prescription Drugs |
| Plan pharmacy (up to a 30-day supply) |
Not covered |
| Mail-order (up to a 100-day supply) |
Not covered |
