|
Monthly Premium
|
$83
|
|
Maximum Out-of-Pocket Expense
|
$4,800
|
|
SERVICES / BENEFITS
|
In-Network
|
Out-of-Network
|
|
Primary Care Physician Office Visit
|
$5
|
$15
|
|
Specialist Office Visit
|
$15
|
$30
|
|
Annual Routine Physical Exam
|
$0
|
$5
|
|
Preventive Services (mammograms,
prostate screening, cholesterol screening, pap smears, immunizations)
|
$0
|
$0-$15
|
|
Diagnostic Radiology Services
|
10%
|
20%
|
|
X-Ray
|
$0
|
20%
|
|
Inpatient Hospitalization
|
$0
|
$150/day
(days 1-5)
|
|
Urgent Care Center
|
$25
|
$25
|
|
Emergency Room
|
$50
|
$50
|
|
Laboratory Services
|
$0
|
20%
|
|
Durable Medical Equipment
|
15%
|
20%
|
|
Home Health Care
|
$0
|
$0
|
|
Rehabilitation Services
(outpatient)
|
$15
|
$30
|
|
Semi-Annual Dental Services
(oral exams, cleanings, dental x-rays)
|
n/a
|
n/a
|
|
Routine Vision Exam
|
$5
|
$15
|
|
Diagnostic / Treatment Vision Exam
|
$5
|
$15
|
|
Hearing Exam (annual)
|
$5
|
$15
|
|
Prescription Drugs
Tier 1
Tier 2
Tier 3
Tier 4
|
$7
$35
$70
25%
|
$73
$353
$703
25%3
|