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$30/$3,000 Deductible Plan w/HSA
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| Features | Member Pays |
Medical calendar year deductible
| Individual/Family | $2,700/$5,450 |
Pharmacy calendar year deductible
| Individual/Family | N/A |
Annual out-of-pocket maximum
| Individual/Family | $5,250/$10,500 |
In the medical office
| Office visits | $30 (after deductible) |
| Preventive physical, vision, and hearing exams | $30 |
| Maternity/prenatal care | $10 |
| Well-child preventive care visits | $10 |
| Vaccines (immunizations) | $0 |
| Allergy injections | $5 (after deductible) |
| Infertility services | Not covered |
| Occupational, physical, and speech therapy | $30 (after deductible) |
| Lab and imaging | $10 (after deductible) |
| MRI/CT/PET | $50 (after deductible) |
| Outpatient surgery | 30% (after deductible) |
Emergency services
| Emergency Department visits (waived if admitted directly to hospital) | 30% (after deductible) |
| Ambulance | $100 (after deductible) |
Prescriptions
| Generic | $10 (after deductible) (up to a 100-day supply) |
| Brand | $30 (after deductible) (up to a 100-day supply) |
| Non-Formulary | Not covered |
Hospital care
| Physicians' services, room and board, tests, medications, supplies, therapies | 30% per admission (after deductible) |
| Skilled nursing facility care | 30% per admission (after deductible) |
Mental health services
| In the medical office (up to 20 visits per calendar year) | $30 (after deductible for individual therapy) $15 (after deductible for group therapy) |
| In the hospital (up to 30 days per calendar year) | 30% per admission (after deductible) |
Chemical dependency services
| In the medical office | $30 (after deductible for individual therapy) |
| In the hospital (detoxification only) | 30% per admission (after deductible) |
Other
| Certain durable medical equipment (DME) DME used in the home in accord with our DME formulary | Not covered |
| Optical (eyewear) | Not covered |
| Vision exam | $30 |
| Home health care (up to 100 two-hour visits per calendar year) | $0 (after deductible) |
| Hospice care | $0 (after deductible) |
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