|
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) |
| TELEMEDICINE SERVICES | $0 |
| DIRECT PRIMARY CARE (DPC) | $10 Copay for Primary Doctor $25 for Urgent Care |
| PRIMARY CARE OFFICE VISIT (when not through the DPC benefit) |
$35 Copay Existing Doctor $70 Copay New Doctor |
| SPECIALIST OFFICE VISIT | $75 Copay Existing Doctor $150 Copay New Doctor |
| LABORATORY SERVICE & RADIOLOGY | $50 Copay Per Panel Tested/ Per Image Billed |
| CT/MRI/MRA/PET SCAN | $500 Copay Per Image Billed |
| URGENT CARE (when not through the DPC benefit) |
$75 Copay |
| OUTPATIENT SERVICES (Limited to Mental & Behavioral Health or Substance Abuse) |
$75 Copay Existing Doctor $150 Copay New Doctor |
| 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 or DPC Product Flyer, as applicable, for a more in-depth list of Benefits Coverage, Limitations and Exclusions. If this document differs from the Schedule of Benefits or DPC Product Flyer, the Schedule of Benefits or DPC Product Flyer, as applicable, will govern.