|
| Covered Services |
Plan
One |
Plan
Two |
Plan
Three |
Plan
Four |
| Monthly premium |
$0 |
$10 |
$55 |
$100 |
| Maximum Out-of-Pocket limit |
$3,000 |
$3,500 |
$2,500 |
$2,000 |
| Prescription Drugs |
|
|
|
|
| - Deductible |
n/a |
$0 |
n/a |
0 |
| - Tier 1 |
n/a |
$7
copay* |
n/a |
$7 copay* |
| - Tier 2 |
n/a |
$33
copay |
n/a |
$33 copay |
| - Tier 3 |
n/a |
$80
copay |
n/a |
$80 copay |
| - Tier 4 |
n/a |
33% |
n/a |
33% |
| Office visits |
|
|
|
|
| PCP |
$10 |
$10 |
$10 |
$5 |
| Specialist |
$35 |
$40 |
$20 |
$10 |
| X-Rays |
15%
of costs |
15% of costs |
%15 of costs |
10% of costs |
| Laboratory services |
15%
of costs |
15% of costs |
%15 of costs |
10% of costs |
| Inpatient Hospital |
$175 copayment |
$230 copayment |
$50 copayment |
$30 copyment |
|
Days 1-6 |
Days 1-6 |
Days 1-6 |
Days 1-6 |
| Outpatient Surgery |
$35 |
$40 |
$20 |
$10 |
| Emergency Room |
$50 |
50 |
$50 |
$50 |
| Urgent Care |
$10 |
$10 |
$10 |
$5 |
| Ambulance Services |
$150 |
$150 |
$100 |
$100 |
| Preventive Care |
|
|
|
|
| - Annual Physical Exam |
$10 |
$10 |
$10 |
$5 |
| - Immunizations |
$0 |
$0 |
$0 |
$0 |
| - GYN exams |
$0 |
$0 |
$0 |
$0 |
| - Screening Mammograms |
$0 |
$0 |
$0 |
$0 |
| - Bone Mass Measurements |
$0 |
$0 |
$0 |
$0 |
| - Colorectal Screening Exams |
$0 |
$0 |
$0 |
$0 |
| - Prostate Screening Exams |
$0 |
$0 |
$0 |
$0 |
| Vision |
n/a |
n/a |
$20 copay/$75 limit 2yrs |
$10 copay $100 limit 2yrs |
| Hearing |
n/a |
n/a |
$20 exam |
$10 exam |
| Dental** |
25% preventive services |
25% preventive services |
25% preventive services |
25% preventive services |
| * Mail order $17.50 for 90day supply |
|
|
|
|
** Allows for up to 2 oral exams, 2 cleanings, and 1 X-ray per year. Amount paid in preventive dental
benefits do NOT apply to your out-of-pocket maximum.
|
