|
 |
| $ 30 |
Office visit Copayment |
| $ 50 |
Specialist visit Copayment |
| $ 1,000 |
Hospital |
| $ 150 |
Emergency Room Copayment |
| $ 300 |
Deductible |
| $ 20 |
Generic |
| $ 30 |
Brand |
| $ 50 |
Non-Formulary Contraceptives included |
SINGLE |
TWO PARTY |
FAMILY |
$468.93 |
$888.89 |
$1,404.76 |
|
| $ 30 |
Office visit Copayment |
| $ 50 |
Specialist visit Copayment |
| $ 2,000 |
In-Network Deductible |
| 80% |
In-Network Co-insurance |
| $ 5,000 |
In-Network Co-insurance Max |
| $ 150 |
Emergency Room copayment |
| $ 4,000 |
Out-Network Deductible |
| 60% |
Out-Network Co-insurance |
| $ 10,000 |
Out-Network Co-insurance Max |
SINGLE |
TWO PARTY |
FAMILY |
$295.39 |
$556.24 |
$875.74 |
|
| |
$ 30 |
Office visit Copayment |
| |
$ 50 |
Specialist visit Copayment |
| |
$ 2,000 |
In-Network Deductible |
| |
80% |
In-Network Co-insurance |
| |
$ 5,000 |
In-Network Co-insurance Max |
| |
$ 150 |
Emergency Room copayment |
| |
$ 4,000 |
Out-Network Deductible |
| |
60% |
Out-Network Co-insurance |
| |
$ 10,000 |
Out-Network Co-insurance Max |
| |
$ 300 |
Deductible |
| |
$ 20 |
Generic |
| |
$ 30 |
Brand |
| |
$ 50 |
Non-Formulary |
SINGLE |
TWO PARTY |
FAMILY |
$343.81 |
$644.65 |
$1,016.49 |
|
|
|
|