CHILD ONLY DEDUCTIBLE PLANS
(individual only) |
$5,000 |
$7,500 |
| Features |
| Deductible |
$5,000 |
$7,500 |
| Out-of-pocket maximum |
$3,750 |
| Lifetime maximum |
$2 million |
| Benefits |
Services not subject to deductible unless otherwise indicated |
| Preventive Care |
| Immunizations |
No charge |
| Routine physicals |
$25 copay |
| Well-baby visits |
| Gynecholgical exams/Mammograms |
| Outpatient services (per visit or procedure) |
| Primary care office visit |
$25 copay |
| Specialty care office visit |
$35 copay (after deductible) |
| Nurse treatment visit (includes allergy injections)1 |
$10 copay |
| Outpatient surgery2 |
$150 copay |
| Lab tests2 |
$10 copay (after deductible) |
| X-rays2 |
$10 copay (after deductible) |
| Inpatient hospital care |
| Inpatient care (including maternity) |
$750 copay per day (after deductible) |
| Maximum per admittance |
$3,750 per admission (after deductible) |
| Maternity coverage |
| Prenatal care (applies to prenatal office visits, one postnatal visit, and lactation consultants) |
$25 copay |
| Emergency & urgent care |
| Emergency Department visit |
20% coinsurance (after deductible) |
| Urgent care visit |
$45 copay |
| Ambulance Service |
20% coinsurance (after deductible) |
| Prescription drugs |
| (up to a 30-day supply) |
$15 or 50%
(whichever is greater) |
| Other services |
| Vision exams |
$25 copay (after deductible) |
| Vision hardware allowance (applies to lenses, frames, and/or contacts every 24 months) |
Not covered |