$1,000 Deductible Plan
| Features | Member pays |
| Medical calendar-year deductible (Individual/Family) | $1,000 / $2,000 |
| Annual out-of-pocket maximum (Individual/Family) | $3,000 / $6,000 |
| Lifetime benefit maximum | None |
| Professional services (plan provider office visits) | |
| Primary and specialty care visits (includes routine and urgent care appointments) | $25 per visit1 |
| Well-child visits from 0 to 23 months | $10 per visit1 |
| Family planning visits | $25 per visit1 |
| Scheduled prenatal care and first postpartum visit | No charge1 |
| Eye exams | $25 per visit1 |
| Hearing tests | $25 per visit1 |
| Physical, occupational, and speech therapy visits | $30 per visit after deductible |
| Outpatient services | |
| Outpatient surgery | $150 per procedure after deductible |
| Allergy injection visits | $5 per visit after deductible |
| Vaccines (immunizations) | No charge1 |
| Most X-rays and lab tests | $10 per encounter after deductible |
| Health education | |
| Individual visits | $25 per visit1 |
| Group visits | No charge1 |
| Hospitalization services | |
| Room and board, surgery, anesthesia, X-rays, lab tests, and medications | $250 per day after deductible |
| Emergency health coverage | |
| Emergency Department visits | $100 per visit after deductible ($100 copayment is waived if admitted directly to the hospital) |
| Ambulance services | |
| Emergency ambulance services | $150 per trip after deductible |
| Prescription drug coverage | |
| Covered items in accord with our drug formulary when obtained at Plan pharmacies | |
| Generic drugs | $10 up to a 30-day supply |
| Brand-name drugs | $35 up to a 30-day supply |
| Mail-order program | $20 generic/$70 brand for 100-day supply of most maintenance drugs |
| Durable medical equipment (DME) | |
| DME used in the home in accord with our DME formulary | 20% coinsurance up to a $1,000 calendar-year benefit limit1 |
| Prosthetic and orthotic devices | No charge |
| Mental health services | |||||||
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| Note: Visit and day limits do not apply to severe mental illness and serious emotional disturbances of children as described in the "Benefits and Cost Sharing" section of the Membership Agreement. |
| Chemical dependency services | |
| Inpatient detoxification | $250 per day after deductible |
| Outpatient individual therapy visits | $25 per visit after deductible |
| Outpatient group therapy visits | $5 per visit after deductible |
| Transitional residential recovery services (up to 60 days per calendar year, not to exceed 120 days in any five-year period) | $250 per admission after deductible |
| Home health services | |
| Home health care (up to 100 two-hour visits per calendar year) | No charge1 |
| Other | |
| Skilled nursing facility care | No charge after deductible (up to 100 days per benefit period) |
| Hospice care | No charge1 |
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(1) These services not subject to the deductible. |
