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$50 Copayment Plan
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| Features | Member Pays |
Medical calendar year deductible
| Individual/Family | $0 |
Pharmacy calendar year deductible
| Individual/Family | $250 for brand prescriptions |
Annual out-of-pocket maximum
| Individual/Family | $3,500/$7,000 |
In the medical office
| Office visits | $50 |
| Preventive physical, vision, and hearing exams | $50 |
| Maternity/prenatal care | $15 |
| Well-child preventive care visits | $15 |
| Vaccines (immunizations) | $0 |
| Allergy injections | $5 |
| Infertility services | Not covered |
| Occupational, physical, and speech therapy | $50 |
| Lab and imaging | $10 |
| MRI/CT/PET | $50 |
| Outpatient surgery | $250 |
Emergency services
| Emergency Department visits (waived if admitted directly to hospital) | $150 |
| Ambulance | $300 |
Prescriptions
| Generic | $10 (up to a 100-day supply) |
| Brand | $35 (after pharmacy deductible) (up to a 100-day supply) |
| Non-Formulary | Not covered |
Hospital care
| Physicians' services, room and board, tests, medications, supplies, therapies | $500 per day |
| Skilled nursing facility care | $0 |
Mental health services
| In the medical office (up to 20 visits per calendar year) | $50 individual/$25 group |
| In the hospital (up to 30 days per calendar year) | $500 per day |
Chemical dependency services
| In the medical office | $50 individual |
| In the hospital (detoxification only) | $500 per day |
Other
| Certain durable medical equipment (DME) DME used in the home in accord with our DME formulary | Not covered |
| Optical (eyewear) | Not covered |
| Vision exam | $50 |
| Home health care (up to 100 two-hour visits per calendar year) | $0 |
| Hospice care | $0 |
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