Calendar Year Deductible |
$7,750 individual; $15,500 family |
Out-of-Pocket Maximum
|
$7,750 individual; $15,500 family
|
Physician Visits
|
First 3 illness-related visits: $40 copay (combined with all other office visits). Thereafter: you pay 0% after you meet the calendar year deductible
|
Telephone and Online Video Consultations |
You pay $45 per consultation
|
Outpatient Surgery
|
Covered at 100%; subject to the calendar year deductible
|
Emergency Room
|
Covered at 100%; subject to the calendar year deductible
|
Pediatric Routine Dental Cleaning and Yearly Eye Exam |
Routine Dental Cleaning: you pay $0; Yearly Eye Exam: you pay 0% after you meet the calendar year deductible |
Prescription Drugs |
Tier 1: $20 copay / Tier 2: $35 copay / Tier 3: You pay 0% after you meet the calendar year deductible / Tier 4: You pay 0% after you meet the calendar year deductible / Tier 5 (preferred specialty): You pay 0% after you meet the calendar year deductible / Tier 6 (nonpreferred specialty): You pay 0% after you meet the calendar year deductible / Generic drugs are mandatory when available |
Notes |
This plan uses the Source+Rx 1.0 Prescription Drug List and the ValueONE Network, which does not include all major retail chains. Check the pharmacy network. |