|
Monthly Premium
|
$0
|
|
Maximum Annual Out-of-Pocket Expense
|
$3,000 In-Network/Out-of-Network
$3,000 Out-of-Network
|
|
SERVICES / BENEFITS
|
In-Network
|
Out-of-Network
|
|
Primary Care Physician Office Visit
|
$10 |
25% |
|
Specialist Office Visit
|
$35 |
25% |
|
Annual Routine Physical Exam
|
$10 |
25% |
|
Preventive Services (mammograms,
prostate screening, cholesterol screening, pap smears, immunizations)
|
$0 |
0-25% |
Skilled Nursing Facility
|
$0
(days 1-20) |
25% |
|
Inpatient Hospitalization
|
$625/stay |
30% |
|
Outpatient Surgery / Services
|
$150 |
25% |
|
Emergency Room
|
$50 |
$50 |
|
Urgent Care
|
$25 |
$25 |
|
Laboratory Services
|
$0 |
25% |
|
Durable Medical Equipment
|
20% |
25% |
|
Home Health Care
|
$0 |
25% |
|
Rehabilitation Services
(outpatient)
|
$35 |
25% |
|
Dental Services (for
Medicare-covered benefits)
|
$35 |
25% |
|
Routine Vision Exam
|
$0 |
25% |
|
Diagnostic / Treatment Vision Exam
|
$35 |
25% |
|
Routine Hearing Exam
|
$0 |
25% |
|
Prescription Drugs
Tier 1
Tier 2
Tier 3
Tier 4
|
$7
$35
$70
25%
|
$73
$353
$703
25%3
|
|
3Prescription Benefit out-of-network costs may be higher than in-network costs. |