| Medical Benefits |
You Pay (In Network) |
| Preventive Services Routine Adult Physical |
$30 per visit (no deductible) |
| Well-Child Care (including exams and immunizations) |
$30 per visit (no deductible) |
| Routine OB/GYN Visits |
$30 per visit (no deductible) |
| PAP test, Mammograms, Prostate Screening & Colorectal Screening Office Visits, Labs and Testing Office Visits (excluding preventive care) 1-2 visits 3+ visits |
No charge $30 per visit (no deductible) Deductible & Coinsurance |
| X-ray and Lab Tests |
Deductible & Coinsurance |
| Allergy Treatments Emergency Care Emergency Room |
Deductible & Coinsurance Deductible & Coinsurance |
| Urgent Care Center |
Deductible & Coinsurance |
| Ambulance (when medically necessary) Hospitalization Inpatient Facility Services |
Deductible & Coinsurance Deductible & Coinsurance |
| Inpatient Physician Services |
Deductible & Coinsurance |
| Outpatient Facility Services |
Deductible & Coinsurance |
| Outpatient Physician Services Vision Services Routine Annual Exam (administered by Davis Vision) Prescription Drug Benefits Deductible |
Deductible & Coinsurance $10 $150 |
| Generic Copay |
$15 |
| Preferred Brand Copay |
Discount |
| Non-Preferred Brand Copay |
Discount |
| Annual Maximum (per person) |
$1,500 (generic drugs) |