| 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 after $200 copay per admission |
30% of the plan allowance |
| Outpatient |
15% of covered charges |
30% of the plan allowance |
| Surgery |
15%* of covered charges |
30%* of the plan allowance |
| Maternity Care |
| Maternity Care |
15%* 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, $30 formulary name brand copayment or $45 non-formulary name brand
copayment; limited to initial fill and one refill per prescription |
| Mail Order (up to 90-day supply) |
$20 generic, 25% ($45 minimum/$80 maximum) formulary name brand copayment or 25%
($60 minimum/$100 maximum) non-formulary name brand copayment |
| Other Benefits |
| Lab and X-rays |
15% of covered charges, no deductible |
30%* of the plan allowance |
| Routine Dental Care |
Any amount over the plan allowance and all charges after the plan has paid $400
|
| Catastrophic Benefits |
Nothing after $4,000 for you and your family members |
Nothing after $6,000 for you and your family members |
