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) |