|
DEDUCTIBLE (Individual | Family) |
$0 | $0 |
|
OUT OF POCKET MAXIMUM (Individual | Family) |
$8,550 | $17,100 |
| PREVENTIVE & WELLNESS SERVICES | $0 Copay (Plan pays 100% of covered preventive and wellness services) |
| TELEMEDICINE SERVICES | $0 Copay |
| PRIMARY CARE OFFICE VISIT | $10 Copay |
| SPECIALIST OFFICE VISIT | $50 Copay (Limited to 8 visits per plan year) |
| LABORATORY SERVICE & RADIOLOGY | $50 Copay (Combined limit of 3 visits per plan year) |
| CT/MRI/MRA/PET SCAN | $350 Copay (Limited to 1 per plan year) |
| URGENT CARE | $25 Copay |
| OUTPATIENT HOSPITAL OR FREE-STANDING FACILITY SERVICES AND SURGERY | $350 Copay (Limited to 1 visit per plan year) |
| INPATIENT HOSPITALIZATION & INPATIENT SURGERY | $350 Copay per admission (Limited to 5 days and 2 Surgeries per plan year) |
| EMERGENCY ROOM SERVICES | $350 Copay (Limited to 1 visit per plan year) |
| PHARMACY BENEFITS (Subject to Formulary) |
Generic - $0 Copay (Limited to Preventive Generic drugs. Plan pays 100% of covered preventive drugs. In addition, a discount pharmacy program is provided that allows other drugs to be obtained at payments ranging from $0 to $50). |
| TREATMENT FOR CHEMICAL ABUSE & DEPENDENCY |
Outpatient: $25 Copay per day Inpatient: $250 Copay per day (Both limited to 5 days per plan year) |
| HOME HEALTH CARE |
$25 Copay (Limited to 10 visits per plan year) |
Please note:
- All benefits must be accessed via telemedicine and scheduling service.
- Out of Network services, and services provided at a hospital, will not be covered, unless otherwise specified.
- Refer to the Schedule of Benefits for a more in-depth list of Benefits Coverage, Limitations and Exclusions. If this document differs from the Schedule of Benefits, the Schedule of Benefits will govern.