$0/$1,500 Deductible Plan with HSA
Features
Individual plan annual deductible (subscriber only)
$1,500
Family plan annual deductible (individual/family)
$3,000/$3,000
Individual plan annual out-of-pocket maximum (subscriber only)
$3,000
Family plan annual out-of-pocket maximum (individual/family)
$6,000/$6,000
Lifetime benefit maximum
None
Benefits
Preventive Care
Immunization
No charge
Routine physical exam
No charge
Well-child visit (0-23 months)
No charge
Well-woman visit
No charge
Mamogram
$10 copay
Outpatient services (per visit or procedure)
Primary care/Specialty office visit
No charge (after deductible)
Most X-rays and lab tests
$10 copay (after deductible)
MRI, CT, and PET
$50 copay (after deductible)
Outpatient surgery
$150 copay (after deductible)
Inpatient hospital care
Room and board, surgery, anesthesia, X-rays, lab tests, and medication
$300 copay per day (after deductible)
Maternity
Maternity care
Covered
Emergency and urgent care
Emergency Department visit (waived if admitted)
$100 copay (after deductible)
Urgent care visit
No charge (after deductible)
Ambulance service
$100 copay (after deductible)
Prescription drugs
Plan Pharmacy (up to a 30-day supply)
Generic: $10 copay/Brand: $35 copay
Mail-order (up to a 100-day supply)
Generic: $20 copay/Brand: $70 copay
