Plan Benefits Summary |
Costs |
| Annual Deductible |
None |
| Lifetime Maximum Benefits |
Unlimited |
| Doctor's Office Visits |
$15 per visit |
| Periodic Health Evaluations |
$15 per visit |
| Well Baby Care (to age 2) |
Covered in Full |
| Prenatal Care |
$15 per visit |
| In-Patient hospital Charges |
20% ($1,500 Max) |
| In-Patient Surgery Charges |
Covered in Full |
| Outpatient Surgery Charges |
20% |
| Lab & X-Ray |
Covered in Full |
| Emergency Room |
$50 per visit |
| Allergy Testing |
$15 per visit |
| Vision & Hearing Exams |
$15 per visit |
Mental Health / Severe
Inpatient |
No Charge |
Mental Health / Severe
Outpatient |
15 per visit |
Mental Health / Non-Severe
Inpatient |
30 Days; No Charge |
Mental Health / Non-Severe
Outpatient |
$30 per visit / 20 visits max |
| Physical Therapy |
$15 per visit |
| Prescription Drugs |
$10 Generic
$20 Brand Name
$35 Non-Formulary |
| Prescription by Mail
(90 day supply) |
2 Co-payments |
| Maximum out-of-pocket |
$1,500 Single
$3,000 Family |
