SERVICES |
$20/$30 OPTION |
$15/$25 OPTION |
$10/$20 OPTION |
|
GENERAL
INFORMATION |
| Member Deductible |
$0 |
$0 |
$0 |
Out-Of-Pocket Max
Subscriber
Two-Party
Family
|
$3,600
$7,200
$11,000 |
$3,000
$6,000
$9,000 |
$2,000
$4,000
$6,000 |
| Lifetime Maximum |
Unlimited |
Unlimited |
Unlimited |
|
| PREVENTIVE SERVICES AND OFFICE
VISITS |
| Well Child - Exams & Immunizations thru
age 17 |
$20/$30 Copay |
$15/$25 Copay |
$10/$20 Copay |
| Adult Routine Preventive Health |
$20/$30 Copay |
$15/$25 Copay |
$10/$20 Copay |
| Routing Gynecological Visits
No charge for PAP Smears |
$20/$30 Copay |
$15/$25 Copay |
$10/$20 Copay |
Prostate Screening Visits
No charge for PSA Test |
$20/$30 Copay |
$15/$25 Copay |
$10/$20 Copay |
| Mammography Screenings |
Covered in Full |
Covered in Full |
Covered in Full |
| Allergy Testing & Treatment |
$20/$30 Copay |
$15/$25 Copay |
$10/$20 Copay |
Annual Routine Eye
Exam
At designated MEC Vision center
At BlueChoice Opthalmologists
(with PCP referral) |
$10
$30 |
$10
$30 |
$10
$30 |
| Hearing Screening |
$20/$30 Copay |
$15/$25 Copay |
$10/$20 Copay |
Rehabilitative Services (Physical,
Occupational & Speech Therapy)
30 visits each per calendar year |
$20/$30 Copay |
$15/$25 Copay |
$10/$20 Copay |
|
| OUTPATIENT MEDICAL AND SURGICAL
SERVICES |
| Physician Office Visit for Illness |
$20/$30 Copay |
$15/$25 Copay |
$10/$20 Copay |
| Surgical Services - Professional |
$20/$30 Copay |
$15/$25 Copay |
$10/$20 Copay |
Surgical Services - Hospital
OR
Diagnostic Procedures |
$50 Facility Copay
PLUS
$20/$30 Copay
$20/$30 Copay |
$50 Facility Copay
PLUS
$15/$25 Copay
$15/$25 Copay |
$50 Facility Copay
PLUS
$10/$20 Copay
$10/$20 Copay |
| X-Ray & Lab Tests at Plan
Facilities |
Covered in Full |
Covered in Full |
Covered in Full |
|
| INPATIENT HOSPITAL SERVICES |
365 Days Room & Board
(Semi Private Room) |
$700 Facility Copay
Per Admission |
$500 Facility Copay
Per Admission |
$250 Facility Copay
Per Admission |
| Medical & Surgical Services |
Covered in Full |
Covered in Full |
Covered in Full |
| Prescription Drugs (Inpatient) |
Covered in Full |
Covered in Full |
Covered in Full |
|
| MATERNITY SERVICES - PRENATAL AND
POSTNATAL CARE |
| PCP |
$20 Per Visit
(up to $200 per pregnancy) |
$15 Per Visit
(up to $150 per pregnancy) |
$10 Per Visit
(up to $100 per pregnancy) |
| Specialist |
$30 Per Visit
(up to $300 per pregnancy) |
$25 Per Visit
(up to $250 per pregnancy) |
$20 Per Visit
(up to $200 per pregnancy) |
| Hospital Facility |
$700 Facility Copay
Per Admission |
$500 Facility Copay
Per Admission |
$250 Facility Copay
Per Admission |
| Delivery |
Covered in Full |
Covered in Full |
Covered in Full |
| Birthing Center |
$30 Per Visit |
$25 Per Visit |
$20 Per Visit |
|
| EMERGENCY OR URGENT CARE |
Plan-Affiliated Urgent Care Facility
Hospital Emergency Room OR
Non-Plan Facility (Waived if Admitted) |
$30
$50 |
$25
$50 |
$20
$50 |
| Ambulance |
Covered in Full |
Covered in Full |
Covered in Full |
|
| PRESCRIPTION DRUGS |
| Deductible |
$150 |
$100 |
$50 |
| Generic Copay |
$10 |
$10 |
$10 |
| Formulary Brand Copay |
$25 |
$25 |
$25 |
| Nonformulary Brand Copay |
$40 |
$40 |
$40 |
| Drug Benefit Maximum |
$500 |
$1,000 |
$1,000 |
|
