|
| Covered Services |
Freedom
3 |
Freedom
5 |
|
| Monthly premium |
$31 |
$34 |
|
| Maximum Out-of-Pocket limit |
$3,350 |
$3,350 |
|
| Prescription Drugs |
|
|
|
| - Deductible |
n/a |
$0 |
|
| - Tier 1 |
n/a |
$7 |
|
| - Tier 2 |
n/a |
$30 |
|
| - Tier 3 |
n/a |
$73 |
|
| - Tier 4 |
n/a |
30% |
|
| Office visits |
|
|
|
| PCP |
$20 |
$15 |
|
| Specialist |
$30 |
$30 |
|
| X-Rays |
$30 copay |
$15 copay |
|
| Laboratory services |
$5 copay |
$5 copay |
|
| Inpatient Hospital |
$265 copay |
$180 copay |
|
|
Days 1-11 |
Days 1-6 |
|
| Outpatient Surgery |
$200 |
$90 |
|
| Emergency Room |
$50 |
$50 |
|
| Urgent Care |
$20 |
$15 |
|
| Ambulance Services |
$150 |
$150 |
|
| Preventive Care |
|
|
|
| - Annual Physical Exam |
$0 |
$0 |
|
| - Immunizations |
$0 |
$0 |
|
| - GYN exams |
$0 |
$0 |
|
| - Screening Mammograms |
$0 |
$0 |
|
| - Bone Mass Measurements |
$0 |
$0 |
|
| - Colorectal Screening Exams |
$0 |
$0 |
|
| - Prostate Screening Exams |
$0 |
$0 |
|
| Vision |
$30 copay/ $100 limit |
$30 copay/ $100 limit |
|
| Hearing |
$30 copay/ $100 limit |
$30 copay/ $100 limit |
|
| Dental |
50% coinsurance |
50% coinsurance |
|
| * Mail order two month copay for 90day supply |
|
|
|
|
