|
DEDUCTIBLE (Individual | Family) |
$0 | $0 |
|
OUT OF POCKET MAXIMUM (Individual | Family) |
$8,150 | $16,300 |
| PREVENTIVE & WELLNESS SERVICES | $0 Copay (Plan pays 100% of covered preventive and wellness services) |
| PRIMARY CARE OFFICE VISIT |
$25 Copay (Combined limit of 6 visits per plan year with Specialist Office Visits.) |
| SPECIALIST OFFICE VISIT | $50 Copay (Combined limit of 6 visits per plan year with Primary Care Office Visits.) |
| OUTPATIENT SERVICES (Limited to Mental & Behavioral Health or Substance Abuse) |
$50 Copay (Considered a Specialist Visit. Combined limit of 6 visits per plan year with Primary Care Office Visit.) |
| 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). |
| SUPPLEMENTAL HOSPITAL BENEFIT | $5,000 (Limited to $1,000 per day; maximum of 5 days) |
Please note:
- 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.