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$5,000 Deductible Plan
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PDF version| Features | |
|---|---|
| Annual deductible | $5,000 |
| Annual out-of-pocket maximum | $7,500 |
| 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 | $50 copay (after deductible) |
| Most X-rays and lab tests | $10 copay (after deductible) |
| MRI, CT, and PET | $50 copay (after deductible) |
| Outpatient surgery | 30% coinsurance (after deductible) |
| Inpatient hospital care | |
| Room and board, surgery, anesthesia, X-rays, lab tests, and medications | 30% coinsurance (after deductible) |
| Maternity | Coverage varies. Please consult the plan’s Certificate of Insurance. |
| Maternity care | Not covered |
| Emergency and urgent care | |
| Emergency Department visit (waived if admitted) | $150 copay (after deductible) |
| Urgent care visit | $50 copay (after deductible) |
| Ambulance service | $150 copay (after deductible) |
| Prescription drugs | |
| Plan pharmacy (up to a 30-day supply) |
Not covered |
| Mail-order (up to a 100-day supply) |
Not covered |
- individual family:
