| Features |
| Annual deductible |
None |
| Annual out-of-pocket maximum |
$3,500 |
| Preventive care |
| Immunizations |
No charge |
| Routine physical exam |
No charge |
| Well-child visit (0-23 months) |
No charge |
| Well-woman visit |
No charge |
| Mammogram screening |
No charge |
| Outpatient services |
| Primary care/Specialty office visit (per visit) |
$50 copay |
| Most X-rays and lab tests (per procedure) |
$10 copay |
| MRI, CT, and PET (per procedure) |
$50 copay |
| Outpatient surgery (per procedure) |
$250 copay |
| Inpatient hospital care |
| Room and board, surgery, anesthesia, X-rays, lab tests, and medication |
$500 copay per day |
| Maternity (coverage varies) |
| Maternity care |
Covered |
| Emergency and urgent care |
| Emergency Department visit (waived if admitted) |
$150 copay |
| Urgent care visit |
$50 copay |
| Ambulance service |
$300 copay |
| Prescription Drugs |
| Plan pharmacy (up to a 30-day supply) |
Not covered |
| Mail-order (up to a 100-day supply) |
Not covered |
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