| |
Prime Plan |
Annual Deductible
Individual/Family |
$10,000/$30,000 |
Annual Out-of-Pocket Maximum
Individual/Family |
$10,000/$30,000 |
| Essential Health Benefit Maximum |
$1,250,000 plan year aggregate limit |
| Accidental Injury Benefit |
The deductible is waived for all covered
services, except for chiropractic services, required to treat an accidental
injury within 90 days of injury. |
|
After meeting your deductible, you pay the following
amounts for covered services:
The deductible is waived for some covered services. These services are marked with †. *Limitations apply. See your Plan Contract for details |
| Preventive Care |
In-Plan |
Out-of-Plan |
| Periodic health exams, well-baby care |
Covered in full † |
Not Covered |
| Routine immunizations/shots |
Covered in full † |
Not Covered |
| Mammograms |
Covered in full † |
Not Covered |
| Gynecological exams, Pap tests |
Covered in full † |
Not Covered |
|
Physician/Provider Services |
| Office visits to a personal physician/provider |
50% † |
Not Covered |
| Office visits to specialists |
50% † |
Not Covered |
| Inpatient hospital visits, surgery and anesthesia |
50% |
Not Covered |
| Hospital Services |
| Inpatient & observation care |
50% |
Not Covered |
| Maternity care |
50% |
Not Covered |
| Routine newborn nursery care |
50% |
Not Covered |
| Rehabilitative care |
50% |
Not Covered |
| Emergency/Urgent care |
| Emergency services |
50% |
Not Covered |
| Urgent care visits |
50% |
Not Covered |
Emergency transportation
|
50% |
Not Covered |
| Outpatient Diagnostic Services |
| X-ray; lab services |
50% |
Not Covered |
| Imaging services (PET, CT, MRI) |
50% |
Not Covered |
| Other Covered Services |
| Medical & diabetes supplies |
50% |
Not Covered |
| Outpatient surgery, radiation therapy, chemotherapy |
50% |
Not Covered |
| Mental health and alcohol treatment |
50% |
Not Covered |
| Prescription Drugs |
| Covered at participating retail and mail-order pharmacies only |
Generic drugs - $20 †
Brand-name drugs - 50% † |
| Alternative care services |
| Acupuncture, chiropractic care, massage therapy and dietitian services |
Receive 25% off provider rates through the Choose Healthy network. |
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