| |
|
| General InformatIon
Member Deductible |
$0
|
|
|
| Out-of-Pocket Maximum
- Individual |
$2,500
|
- Individual & Child(ren)*/Individual & Adult**
|
$5,000
|
- Family
|
$5,000
|
|
|
Lifetime Maximum |
No lifetime maximum |
| |
|
|
|
|
| PREVENTIVE SERVICES & OFFICE VISITS |
|
| Well-Child - Exams & Immunizations through age 17 |
$10 PCP/$20 Specialist |
| Adult Routine Preventive Health |
$10 PCP/$20 Specialist |
| Routine Gynecological Visits (No Charge for Pap Smear) |
$10 PCP/$20 Specialist |
| Mammography Screenings |
No copay |
| Prostate Screening Visits (No Charge for PSA test) |
$10 PCP/$20 Specialist |
| Colorectal Cancer Screening (in accordance with the most current American Cancer Society guidelines) |
No copay |
| Allergy Testing and Treatment |
$10 PCP/$20 Specialist |
| Annual Routine Eye Exam at designated Davis Vision provider (optometrists or ophthalmologists) |
$10 |
| Hearing Screening |
$10 PCP/$20 Specialist |
| |
|
| OUTPATIENT MEDICAL & SURGICAL SERVICES
Physician Office Visit for Illness |
$10 PCP/$20 Specialist
|
| Spinal Manipulation |
$10 PCP/$20 Specialist |
| Surgical Services-Professional |
$10 PCP/$20 Specialist |
| Surgical Services-Hospital or Other Facility |
$50 facility copay |
| Diagnostic Procedures |
$10 PCP/$20 Specialist |
| X-rays and Lab Tests at Plan Facilities |
No copay |
| |
|
| INPATIENT HOSPITAL SERVICES
365 Days Room and Board (Semi-Private Room) |
$500 facility copay per admission
|
| Medical and Surgical Services |
No copay |
| Prescription Drugs (Inpatient) |
No copay |
| |
|
| EMERGENCY OR URGENT CARE
Plan-Affiliated Urgent Care Facility |
$20
|
| Hospital Emergency Room or Non-Plan Facility (waived if admitted) |
$50 |
| Ambulance |
No copay |
| |
|
Mental Health and Substance Abuse
Outpatient services
|
Visits 1-40: 25% of the Allowed Benefit
Visits 41+: 40% of the Allowed Benefit
|
Inpatient Facility Services
(Limited to 60 days per benefit period) |
$500 facility copay per admission |
Inpatient Professional Services
(Limited to one visit per day during a covered admission) |
No copay |
|
|
Maternity Services
Prenatal and Postnatal Care |
Not covered |
Room and Board |
$500 facility copay per admission |
In-Patient Physician Services |
Not covered |
Nursery Care of Newborn |
No copay |
|
|
PRESCRIPTION DRUGS |
|
Annual Deductible |
$100 Individual, $200 Individual & Adult,
Individual & Child(ren), Family |
|
|
Tier 1 – Generic copay |
$10
|
Tier 2 – Preferred Brand copay |
$60 |
Tier 3 – Non-Preferred Brand copay |
$80 |
Annual drug benefit maximum |
$1,500 per member per benefit period |