Plan Benefits Summary |
Costs |
| Annual
Deductible |
NONE |
| Lifetime
Maximum Benefits |
Unlimited |
| Doctor's
Office Visits |
$20 per visit |
| Periodic Health Evaluations |
$20 per visit |
| Well Baby Care (to age 2) |
Covered in Full |
| Prenatal Care |
$20 per visit |
In-Patient
hospital Charges
|
$1,500 per Admit |
| In-Patient
Surgery Charges |
Covered in Full |
| Outpatient
Surgery Charges |
20% |
| Lab &
X-Ray |
Covered in Full |
| Emergency
Room |
$50 per visit |
| Allergy
Testing |
$20 per visit |
| Vision &
Hearing Exams |
$20 per visit |
Mental Health
/ Severe
Inpatient |
No Charge |
| Outpatient |
$20 per visit |
Mental Health
/ Non-Severe
Inpatient |
30 Days; No Charge |
| Outpatient |
$20 per visit / 20 visits
max |
| Physical
Therapy |
$20 per visit |
Prescription Drugs
|
$15 Generic /
$25 Brand Name
$35
Non-Formulary
$1,00 Cal. Year Limit |
Prescription
by Mail
(90 day supply) |
2 Co-payments |
|
Maximum out-of-pocket |
$2,500 single /
$5,000 family
|
