Highlights
Emergency Room:
30% Coinsurance after deductible
Retail Drugs:
$45 Copay after deductible
Overview
Health Spending Account:
No
Primary Care Office Visit:
$35
Specialist Office Visit:
$60
Out of Network Coverage:
No
Out of Country Coverage:
No
Coverage Details
Preventive Care
Periodic Health Exam
In Network:
Not Applicable
Out of Network:
Not Covered
Well Baby Care
Out of Network:
Not Covered
Inpatient
Hospital Services
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
Physician Fee
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
Skilled Nursing Facility
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
Mental Health
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
Substance Abuse
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
Home Healthcare
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
Outpatient
Surgery
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
X-ray and Diagnostics
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
Labs
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
Facility Fee
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
Mental Health
Out of Network:
Not Covered
Substance Abuse
Out of Network:
Not Covered
Rehabilitation Services
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
Maternity/Pregnancy
Pre & Postnatal Care
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
Labor and Delivery Inpatient Services
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
Dental
Accidental Care
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
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:
Not Covered
Habilitation Services
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
Rehabilitation Services (Speech)
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
Rehabilitation Services (Occupational Therapy)
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
Hospice Service
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
Diabetes Care Management
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
Durable Medical Equipment
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
Nutritional Consuleling
Out of Network:
Not Covered
Reconstructive Surgery
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
Doctor Visits
Primary Care Visit
Out of Network:
Not Covered
Specialist Visit
Out of Network:
Not Covered
Other Practitioner Office Visit
Out of Network:
Not Covered
Preventative Care / Screening / Immunization
In Network:
Not Applicable
Out of Network:
Not Covered
Emergency Room and Urgent Care
Emergency Room Services
In Network:
30% Coinsurance after deductible
Out of Network:
30% Coinsurance after deductible
Urgent Care Services
Out of Network:
Not Covered
Ambulance/Transportation Services
In Network:
20% Coinsurance after deductible
Out of Network:
Not Covered
Drugs
Generic Prescription
Out of Network:
Not Covered
Retail Brand Drugs
In Network:
$45 Copay after deductible
Out of Network:
Not Covered
Non Retail Brand Drugs
In Network:
30% Coinsurance after deductible
Out of Network:
Not Covered
Specialty Drugs
In Network:
30% Coinsurance after deductible
Out of Network:
Not Covered
Drug Deductible
In Network:
Individual: $250 Family: $500
Out of Network:
Individual: Not Applicable Family: Not Applicable
Additional Plan Information