$50 Copayment Plan
Features
Individual plan annual deductible (subscriber only)
None
Family plan annual deductible (individual/family)
None
Individual plan annual out-of-pocket maximum (subscriber only)
$3,500
Family plan annual out-of-pocket maximum (individual/family)
$3,500/$7,000
Lifetime benefit maximum
None
Benefits
Preventive Care
Immunization
No charge
Routine physical exam
$50 copay
Well-child visit (0-23 months)
$15 copay
Well-woman visit
$50 copay
Mamogram
$10 copay
Outpatient services (per visit or procedure)
Primary care/Specialty office visit
$50 copay
Most X-rays and lab tests
$10 copay
MRI, CT, and PET
$50 copay
Outpatient surgery
$250 copay
Inpatient hospital care
Room and board, surgery, anesthesia, X-rays, lab tests, and medication
$500 copay per day
Maternity
Maternity care
Covered
Emergency and urgent care
Emergency Department visit (waived if admitted)
$150 copay
Urgent care visit
$50 copay
Ambulance service
$300 copay
Prescription drugs
Plan Pharmacy (up to a 30-day supply)
Not covered
Mail-order (up to a 100-day supply)
Not covered
