|
| Covered Services |
Freedom
2 |
Freedom
3 |
Freedom
5 |
| Monthly premium |
$23 |
$0 |
$36 |
| Maximum Out-of-Pocket limit |
$3,000 |
$3,350 |
$3,350 |
| Prescription Drugs |
|
|
|
| - Deductible |
n/a |
n/a |
$0 |
| - Tier 1 |
n/a |
n/a |
$7 |
| - Tier 2 |
n/a |
n/a |
$30 |
| - Tier 3 |
n/a |
n/a |
$73 |
| - Tier 4 |
n/a |
n/a |
30% |
| Office visits |
|
|
|
| PCP |
$15 |
$20 |
$15 |
| Specialist |
$30 |
$30 |
$30 |
| X-Rays |
$15 copay |
$30 copay |
$15 copay |
| Laboratory services |
$5 copay |
$5 copay |
$5 copay |
| Inpatient Hospital |
$180 copay |
$265 copay |
$180 copay |
|
Days 1-5 |
Days 1-11 |
Days 1-6 |
| Outpatient Surgery |
$90 |
$200 |
$90 |
| Emergency Room |
$50 |
$50 |
$50 |
| Urgent Care |
$15 |
$20 |
$15 |
| Ambulance Services |
$150 |
$150 |
$150 |
| Preventive Care |
|
|
|
| - Annual Physical Exam |
$0 |
$0 |
$0 |
| - Immunizations |
$0 |
$0 |
$0 |
| - GYN exams |
$0 |
$0 |
$0 |
| - Screening Mammograms |
$0 |
$0 |
$0 |
| - Bone Mass Measurements |
$0 |
$0 |
$0 |
| - Colorectal Screening Exams |
$0 |
$0 |
$0 |
| - Prostate Screening Exams |
$0 |
$0 |
$0 |
| Vision |
$30 copay/ $100 limit |
$30 copay/ $100 limit |
$30 copay/ $100 limit |
| Hearing |
$30 copay/ $100 limit |
$30 copay/ $100 limit |
$30 copay/ $100 limit |
| Dental |
50% coinsurance |
50% coinsurance |
50% coinsurance |
| * Mail order two month copay for 90day supply |
|
|
|
|
