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Permian Basin Employer Health Plan D |
|
Covered Services
|
Member Responsibility |
| Aggregate Lifetime Maximum Benefit |
$500,000 |
| Calendar Year Deductible |
$30,000 per Member |
|
| Doctor Office Visits
|
Primary Care Physician |
$50 per visit |
|
Specialty Care |
$75 per visit |
|
|
Limited Inpatient Services |
Tier 1 Hospital
(contracted, within the Service Area) |
$500 per admission
(no Deductible) |
|
Tier 2 Hospital
(contracted, outside the Service Area) |
30% of the allowable amount
after deductible |
|
| Emergency Care Services |
Emergency Room |
$500 per visit
(copay is waived if admitted) |
| Urgent Care or Minor Emergency |
$50 per visit |
For more detailed information visit the plan documents:
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