Summary of Medical Benefits
$500 Copay Plan
In-Network
Out-of-Network
Deductible Individual Family |
$500 $1,000 |
$1,000 $2,000 |
Out-of-Pocket Maximum Individual Family |
$500 $1,000 |
$2,000 $4,000 |
Preventive Care Services |
No Charge |
50%* |
Office Visits Primary Office Visit Specialist Office Visit Chiropractic Visit |
$25 Copay $75 Copay 0%* |
50%* 50%* 50%* |
Urgent Care Services |
$50 Copay |
50%* |
Complex Imaging: MRI/CT/PET Scans |
0%* |
50%* |
Inpatient Hospital Care Facility Fee Physician Fee |
0%* 0%* |
50%* 50%* |
Outpatient Procedures Facility Fee Physician Fee |
0%* 0%* |
50%* 50%* |
Emergency Room Emergency Medical Transportation |
$300 Copay, then 0%* 0%* |
$300 Copay, then 0%* 0%* |
Mental Health/Chemical Dependency Inpatient Office Visit |
0%* $25 Copay |
50%* 50%* |
Prescription Drug Coverage Generic Preferred Brand Non-Preferred Brand Specialty Drugs |
Retail 30 Day Supply $5 Copay $30 Copay $65 Copay $150 Copay |
Mail Order 90 Day Supply $12.50 Copay $75 Copay $162.50 Copay Not Available |
NOTE: * Coinsurance after deductible Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions |
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