| Preventive Care |
| Well-child Office Visits |
Nothing for covered charges |
30%* of the plan allowance |
| Cancer Screening |
Nothing for covered charges |
30%* of the plan allowance |
| Annual Physicals |
$20 copay per office visit |
30%* of the plan allowance |
| Physician Care |
| Doctor's Office Visits |
$20 copay per office visit |
30%* of the plan allowance |
| Hospital Care |
| Inpatient |
Nothing for room and board;
10% after $200 copay per admission |
30% after $300 copay per admission |
| Outpatient |
10% of covered charges, $100 copay |
30% of the plan allowance, $150 copay |
| Surgery |
10%* of covered charges |
30%* of the plan allowance |
| Maternity Care |
| Maternity Care |
10%* of covered charges |
30%* of the plan allowance |
| Emergency Care |
| Accidental Injury |
Nothing within 72 hours |
Nothing within 72 hours |
| Medical Emergency |
Regular Benefits apply |
Regular Benefits apply |
| Prescription Drugs |
| Retail (up to 30 day supply) |
$10 generic, $25 formulary name brand copayment or $40 non-formulary name brand
copayment; with no limits on refills |
| Mail Order (up to 90-day supply) |
$10 generic, $45 formulary name brand copayment or $60 non-formulary name brand
copayment. Medicare Part B Enrollees: $5 generic, $20 formulary name brand or $35 non-formulary name brand copayment |
| Other Benefits |
| Lab and X-rays |
10% of covered charges, no deductible |
30%* of the plan allowance |
| Home Health Aide |
10%* of covered charges, 100 visits |
30%* of the plan allowance, 100 visits |
| Catastrophic Benefits |
Nothing after $3,500 for you and your family members |
Nothing after $5,000 for you and your family members |
