| Key benefits | Silver 87 |
|---|---|
| Benefits in Orange are Subject to the Annual deductible amounts listed below. You will pay the full cost for these services until the Deductible is met. Then you will pay the specified amount that is shown until the Annual Maximum Out-of-Pocket is met. The deductible counts toward the Maximum Out-Of-Pocket. |
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| Copays in Black are NOT Subject to any Deductible and count towards the Annual Maximum Out-Of-Pocket. The Annual Out-Of-Pocket Maximum and Deductible amounts are always based on the Individual amount listed even under a family plan. Two or more people in the family have to reach the family amounts listed below in order for them to apply to the entire family. |
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| Individual Deductible | $800 medical $0 pharmacy |
| Family Deductible | $1,600 medical $0 pharmacy |
| Preventative Care | no cost1 |
| Primary Care Visit Copay | $15 |
| Specialty Care Visit Copay | $25 |
| Urgent Care Visit Copay | $15 |
| Mental Health & Substance Abuse Outpatient Office Visits | $15 |
| Lab Testing Copay | $20 |
| X-Ray Copay | $40 |
| Imaging Copay | $100 |
| Outpatient services | 15% |
| Emergency Room Copay | $150 |
| Emergency Room Transportation Copay | $75 |
| Prenatal care during Pregnancy and preconception visits | No charge1 |
| Inpatient Hospital Stay (e.g. Labor & Delivery, Mental Health, Substance abuse, surgery, etc) | $15% |
| Tier 1 - Most Generic Drugs | $5 |
| Tier 2 - Preferred Brand Drugs | $25 |
| Tier 3 - Non-Preferred Brand Drugs | $45 |
| Tier 4 - Specialty Drugs | 15% up to $150 maximum per prescription |
| Maximum Out-Of-Pocket For One | $2,850 |
| Maximum Out-Of-Pocket For Family | $5,800 |
| 1 in-network only 2 Copay is limited to the first three non-preventive visits. That includes any combination of Primary Care, Specialist, Mental Health or Urgent Care visits. After three visits, future visits will be at full cost until the deductible is met and then the copay shown will apply again. 3 See the plan's Summary of Benefits to determine if Copay or Coinsurance is due. |
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| Key benefits | Silver 87 |