Highlights
Emergency Room:
20% coinsurance after deductible
Retail Drugs:
20% coinsurance after deductible
Generic Drugs:
20% coinsurance after deductible
Overview
Primary Care Office Visit:
20% coinsurance after deductible
Specialist Office Visit:
20% coinsurance after deductible
Out of Network Coverage:
Not Covered
Out of Country Coverage:
Not Covered
Coverage Details
Preventive Care
Periodic Health Exam
Out of Network:
50% coinsurance after deductible U&C
Well Baby Care
Out of Network:
50% coinsurance after deductible U&C
Inpatient
Hospital Services
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Physician Fee
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Skilled Nursing Facility
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Mental Health
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Substance Abuse
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Home Healthcare
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Outpatient
X-ray and Diagnostics
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Labs
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Facility Fee
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Mental Health
Out of Network:
50% coinsurance after deductible U&C
Substance Abuse
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Maternity/Pregnancy
Pre & Postnatal Care
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Labor and Delivery Inpatient Services
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Dental
Accidental Care
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Basic Dental Care (Child)
In Network:
20% coinsurance after deductible
Out of Network:
20% coinsurance after deductible
Dental Checkup (Child)
In Network:
20% coinsurance after deductible
Out of Network:
20% coinsurance after deductible
Major Dental Care (Child)
In Network:
20% coinsurance after deductible
Out of Network:
20% coinsurance after deductible
Orthodontia (Child)
In Network:
20% coinsurance after deductible (requires prior authorization)
Out of Network:
20% coinsurance after deductible (requires prior authorization)
Vision
Eye Exam (Child)
In Network:
20% coinsurance after deductible
Out of Network:
20% coinsurance after deductible
Glasses (Child)
In Network:
20% coinsurance after deductible
Out of Network:
20% coinsurance after deductible
Additional Coverage
Chiropractic Care
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Rehabilitation Services (Speech)
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Rehabilitation Services (Occupational Therapy)
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Hospice Service
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Durable Medical Equipment
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Doctor Visits
Primary Care Visit
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Specialist Visit
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Preventative Care / Screening / Immunization
Out of Network:
50% coinsurance after deductible U&C
Emergency Room and Urgent Care
Emergency Room Services
In Network:
20% coinsurance after deductible
Out of Network:
20% coinsurance after deductible
Urgent Care Services
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Ambulance/Transportation Services
In Network:
20% coinsurance after deductible
Out of Network:
20% coinsurance after deductible
Drugs
Generic Prescription
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Retail Brand Drugs
In Network:
20% coinsurance after deductible
Out of Network:
50% coinsurance after deductible U&C
Non Retail Brand Drugs
Out of Network:
50% coinsurance after deductible U&C
Specialty Drugs
In Network:
20% coinsurance after deductible
Out of Network:
Not Applicable
Additional Plan Information