Monthly Premium
|
$90
|
Medical Out-of-Pocket Maximum
|
In Network: $4,900
Out-of-Network: $9,9999
|
Office Visits ($0 annual preventive exam)
|
In Network: $25
Out-of-Network: $659
|
Specialist Office Visits
|
In Network: $40
Out-of-Network: $659
|
Inpatient Hospital
|
In Network: $275 per day for days 1-5, per admission
Out-of-Network: 30% PA9
|
Inpatient Hospital Maximum (per calendar year)
|
In Network: No maximum per calendar year
Out-of-Network: No maximum per calendar year9
|
Outpatient Surgery
2
|
In Network: $450
Out-of-Network: 30% PA9
|
Skilled Nursing Facility (SNF)
2
|
In Network:
Days 1–20:
$0 copay per day
Days 21–50:
$120 copay per day
Days 51–100:
$0 copay per day
Out-of-Network:
30% per day PA
9
|
Teladoc Virtual Doctor Visits
8
|
In Network: $25
Out-of-Network: N/A
|
Urgent Care
|
In Network: $50
Out-of-Network: $509
|
World Wide Emergency Room (ER)
|
In Network: $90
Out-of-Network: $909
|
Ambulance
2
|
In Network: $150
Out-of-Network: 30% PA9
|
Outpatient Rehabilitation (PA after 25 visits)
3
|
In Network: $40
Out-of-Network: 30% PA9
|
High Cost Imaging
2
|
In Network: $225
Out-of-Network: 30% PA9
|
Lab Work / X-rays
|
In Network: $0 Labs / $20 X-rays
Out-of-Network: 30% PA9
|
Durable Medical Equipment and Prosthetics
2
|
In Network: 20% coinsurance
Out-of-Network: 30% PA9
|