Benefit |
Benefit Details |
| Monthly Cost | Monthly Cost Includes:
|
| Deductible(s) | $3,500 (Does not apply to Tier 1 and Tier 2 |
| Primary Care Visit to Treat an Injury or Illness | You pay $45.00 – not subject to deductible |
| Out of Pocket Max | $4,500 (includes deductible) |
| Specialist Visit | You pay 0% after deductible |
| Most Generic Drugs (Tier 1) | 30 day Retail: You pay $15.00 – not subject to deductible 90 day Mail Order: You Pay $30.00 – not subject to deductible |
| Most Preferred Brand Drugs (Tier 2) | 30 day Retail: You Pay $40.00 – not subject to deductible 90 day Mail Order: You pay $100.00 – not subject to deductible |
| Most Non-Preferred Brand Drugs (Tier 3) | 30 day Retail: You pay 0% after deductible 90 day Mail Order: You pay 20% after deductible |
| Most Specialty Drugs (Tier 4) | 30 day Retail or Mail Order: You Pay 0% after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay) | You pay $500.00 after deductible |
| Outpatient Surgery Physician/Surgical Services | You pay 0% |
| Emergency Room Services | You pay $200.00 |
| HSA Compatible | No |
| Mental/Behavioral Health Outpatient Services | You pay 0% after deductible |
| Urgent Care Centers or Facilities | You pay $50.00 after deductible |
| X-rays and Diagnostic Imaging | You pay 0% after deductible |
| Chiropractic Care | You pay 0% 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 0% after deductible |
| Laboratory Outpatient and Professional Services | You pay 0% after deductible |
| Mental/Behavioral Health Inpatient Services | You pay $500.00 after deductible |
| Delivery and All Inpatient Services for Maternity Care | You pay $500.00 after deductible |
| Inpatient Physician and Surgical Services | You pay 0% after deductible |
| Emergency Transportation/Ambulance | You pay 0% after deductible |
| Allergy Testing | You pay 0% after deductible |
| Durable Medical Equipment | You pay 0% after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | You pay 20% after deductible |
| Diabetes Care Management | You pay 0% after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | You pay $45.00 – not subject to deductible |
| Outpatient Rehabilitation Services | Occupational Therapy: You pay 0% 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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This website is operated by Nefouse & Associates Inc. We are certified to offer the federal exchange so we do comply with Personal Identifiable Information. This means any information you submit to this website will not be sold or misused. We will only use that information to assist you with obtaining a health insurance policy. At any time you may request us to destroy/deleted all information you have submitted. These are the rules under 45 CFR 155.220(c) and (d) and standards established under 45 CFR 155.260 that protect your privacy.
This website is operated by Nefouse & Associates Inc. We are certified to offer the federal exchange so we do comply with Personal Identifiable Information. This means any information you submit to this website will not be sold or misused. We will only use that information to assist you with obtaining a health insurance policy. At any time you may request us to destroy/deleted all information you have submitted. These are the rules under 45 CFR 155.220(c) and (d) and standards established under 45 CFR 155.260 that protect your privacy.
