| Features |
| Annual deductible |
$1,000 |
| Annual out-of-pocket maximum |
$3,000 |
| Benefits |
Services not subject to deductible unless otherwise indicated |
| Preventive care |
| Immunizations |
No charge |
| Routine physical exam |
No charge |
| Well-child visit (0 to 23 months) |
No charge |
| Well-woman visit |
No charge |
| Mammogram screening |
No charge |
| Outpatient services (per visit or procedure) |
| Primary care/Specialty office visit |
$25 copay |
| Most X-rays and lab tests |
$10 copay (after deductible) |
| MRI, CT, and PET |
$50 copay (after deductible) |
| Outpatient surgery |
$150 copay (after deductible) |
| Inpatient hospital care |
| Room and board, surgery, anesthesia, X-rays, lab tests, and medications |
$250 copay per day (after deductible) |
| Maternity |
Coverage varies. Please consult the plan’s Membership Agreement. |
| Maternity care |
Covered (after deductible) |
| Emergency and urgent care |
| Emergency Department visit (waived if admitted) |
$100 copay (after deductible) |
| Urgent care visit |
$25 copay |
| Ambulance service |
$150 copay (after deductible) |
| Prescription drugs |
| Plan pharmacy (up to a 30-day supply) |
- Generic: $10 copay
- Brand: $35 copay
|
| Mail-order (up to a 100-day supply) |
- Generic: $20 copay
- Brand: $70 copay
|
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