Highlights
Emergency Room:
20% Coinsurance after deductible
Retail Drugs:
$30 Copay after deductible
Overview
Health Spending Account:
No
Primary Care Office Visit:
20% Coinsurance after deductible
Specialist Office Visit:
20% Coinsurance after deductible
Out of Network Coverage:
No
Out of Country Coverage:
No
Coverage Details
Preventive Care
Periodic Health Exam
Out of Network:
30% Coinsurance after deductible
Well Baby Care
Out of Network:
30% Coinsurance after deductible
Inpatient
Hospital Services
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Physician Fee
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Skilled Nursing Facility
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Mental Health
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Substance Abuse
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Home Healthcare
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Outpatient
Surgery
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
X-ray and Diagnostics
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Labs
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Facility Fee
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Mental Health
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Substance Abuse
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Rehabilitation Services
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Maternity/Pregnancy
Pre & Postnatal Care
Out of Network:
30% Coinsurance after deductible
Labor and Delivery Inpatient Services
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Dental
Accidental Care
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Basic Dental Care (Child)
Out of Network:
Not Covered
Dental Checkup (Child)
Out of Network:
Not Covered
Major Dental Care (Child)
Out of Network:
Not Covered
Orthodontia (Child)
Out of Network:
Not Covered
Vision
Eye Exam (Child)
Out of Network:
Not Covered
Glasses (Child)
Out of Network:
Not Covered
Additional Coverage
Chiropractic Care
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Habilitation Services
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Rehabilitation Services (Speech)
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Rehabilitation Services (Occupational Therapy)
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Hospice Service
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Diabetes Care Management
Out of Network:
30% Coinsurance after deductible
Durable Medical Equipment
Out of Network:
30% Coinsurance after deductible
Nutritional Consuleling
Out of Network:
30% Coinsurance after deductible
Reconstructive Surgery
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Doctor Visits
Primary Care Visit
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Specialist Visit
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Other Practitioner Office Visit
In Network:
20% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Preventative Care / Screening / Immunization
Out of Network:
30% Coinsurance after deductible
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:
30% Coinsurance after deductible
Ambulance/Transportation Services
In Network:
20% Coinsurance after deductible
Out of Network:
20% Coinsurance after deductible
Drugs
Retail Brand Drugs
In Network:
$30 Copay after deductible
Out of Network:
$30 Copay after deductible
Non Retail Brand Drugs
In Network:
$50 Copay after deductible
Out of Network:
$50 Copay after deductible
Specialty Drugs
In Network:
30% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Drug Deductible
In Network:
Individual: Not Applicable Family: Not Applicable
Out of Network:
Individual: Not Applicable Family: Not Applicable
Additional Plan Information