Benefit |
Benefit Details |
| Monthly Cost | Monthly Cost Includes:
|
| Deductible(s) | $5,750 (Does not apply to Tier 1 and Tier 2 |
| Primary Care Visit to Treat an Injury or Illness | You pay $40.00 – not subject to deductible, for the first 2 visits. For additional visits you pay 20% after deductible |
| Out of Pocket Max | $6,600 (includes deductible) |
| Specialist Visit | You pay 20% after deductible |
| Most Generic Drugs (Tier 1) | 30 day Retail: You pay $25.00 – not subject to deductible 90 day Mail Order: You Pay $50.00 – not subject to deductible |
| Most Preferred Brand Drugs(Tier 2) | 30 day Retail: You Pay $55.00 – not subject to deductible 90 day Mail Order: You pay $137.50 – not subject to deductible |
| Most Non-Preferred Brand Drugs (Tier 3) | 30 day Retail: You pay 20% after deductible 90 day Mail Order: You pay 20% after deductible |
| Most Specialty Drugs (Tier 4) | 30 day Retail or Mail Order: You Pay 20% after deductible |
| Inpatient Hospital Services(e.g., Hospital Stay) | You pay $500.00 and 20% after deductible |
| Outpatient Surgery Physician/Surgical Services | You pay 20% after deductible |
| Emergency Room Services | You pay $200.00 and 20% after deductible |
| HSA Compatible | No |
| Mental/Behavioral Health Outpatient Services | You pay 20% after deductible |
| Urgent Care Centers or Facilities | You pay $50.00 and 20% after deductible |
| X-rays and Diagnostic Imaging | You pay 20% after deductible |
| Chiropractic Care | You pay 20% after deductible limited to 12 Visit(s) Per Calendar Year |
| Preventive Care/Screening/Immunization | You pay 0% – not subject to deductible |
| Prenatal and Postnatal Care | You pay 20% after deductible |
| Imaging (CT/PET Scans, MRIs) | You pay 20% after deductible |
| Laboratory Outpatient and Professional Services | You pay 20% after deductible |
| Mental/Behavioral Health Inpatient Services | You pay $500.00 and 20% after deductible |
| Delivery and All Inpatient Services for Maternity Care | You pay $500.00 and 20% after deductible |
| Inpatient Physician and Surgical Services | You pay 20% after deductible |
| Emergency Transportation/Ambulance | You pay 20% after deductible |
| Allergy Testing | You pay 20% after deductible |
| Durable Medical Equipment | You pay 20% after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | You pay 20% after deductible |
| Diabetes Care Management | You pay 20% after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | You pay $40.00 – not subject to deductible, for the first 2 visits. For additional visits you pay 20% after deductible |
| Outpatient Rehabilitation Services | Occupational Therapy: You pay 20% after deductible limited to 20 Visit(s) Per Year Physical Therapy: You pay 20% after deductible limited to 20 Visit(s) Per Year Speech Therapy: You pay 20% after deductible limited to 20 Visit(s) Per Year |
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