Annual Deductible

None

Annual Copay Maximum

$2,500 Individual / $7,500 Family

Lifetime Maximum

Unlimited

Office Visits non-specialist & specialist

You pay nothing, after $12 copay

Adult includes routine physical exams, routine gynecological exam (including PAP test), mammograms (as required)

You pay nothing

Pediatric includes routine physical exams, pediatric immunizations

You pay nothing

Emergency Room Services

You pay 20%

Urgent Care

You pay $12 copay

Ambulance

You pay 20%

Inpatient

You pay 10%

Outpatient Laboratory, Pathology & Surgical

You pay 20%

Maternity

You pay 10%

Diagnostic Services, Outpatient Speech Therapy and Occupational Therapy, Durable Medical Equipment

You pay 20%

Hospice

You pay nothing

Outpatient Hospital & Inpatient Services

You pay 10%

Outpatient Physician Services

You pay $12 copay

Out-of-Pocket Maximum

$3,600 Individual/$4,200 family

Retail up to 31-day supply

• Generic: $7 copay
• Preferred Brand Name: $30 copay
• Other Brand Name: $30 plus $45 other brand name cost share
• Specialty (for non-preferred formulary): $200 copay
• Specialty (preferred formulary): $100 copay

Mail Order up to 90-day supply

• Generic: $11 copay
• Preferred Brand Name: $65 copay
• Other Brand Name: $65 plus $135 other Brand Name cost share