$30/$2,500 Deductible Plan w/HRA

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Once you've compared the plan coverage and benefit details, you can:

  Features Member Pays

Medical calendar year deductible

Individual/Family $2,500/$5,000

 

Pharmacy calendar year deductible

Individual/Family $250 for brand prescriptions

 

Annual out-of-pocket maximum

Individual/Family $5,000/$10,000

In the medical office

Office visits $30 (after deductible)
Preventive physical, vision, and hearing exams $30
Maternity/prenatal care $10
Well-child preventive care visits $10
Vaccines (immunizations) $0
Allergy injections $0
Infertility services Not covered
Occupational, physical, and speech therapy $30 (after deductible)
Lab and imaging $10 (after deductible)
MRI/CT/PET $50 (after deductible)
Outpatient surgery 20% (after deductible)

Emergency services

Emergency Department visits (waived if admitted directly to hospital) 20% (after deductible)
Ambulance $150 (after deductible)

 

Prescriptions

Generic $10
Brand $35 (after $250 pharmacy deductible)
Non-Formulary Not covered

Hospital care

Physicians' services, room and board, tests, medications, supplies, therapies 20% per admission (after deductible)
Skilled nursing facility care 20% per day (after deductible) (up to 100 days per benefit period)

Mental health services

In the medical office (up to 20 visits per calendar year) $30 (after deductible for individual therapy) $15 (after deductible for group therapy)
In the hospital (up to 30 days per calendar year) 20% per admission (after deductible)

Chemical dependency services

In the medical office $30 (after deductible for individual therapy)
In the hospital (detoxification only) 20% per admission (after deductible)

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 $30
Home health care (up to 100 two-hour visits per calendar year) $0
Hospice care $0