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Permian Basin Employer Health Plan A - Low 2000 |
|
Covered Services
|
Member Responsibility |
| Aggregate Lifetime Maximum Benefit |
$750,000 |
| Calendar Year Deductible |
$2,000 per Member |
| Out-of-Pocket Maximum |
$20,000 per Member |
|
| Doctor Office Visits
|
Primary Care Physician |
$25 per visit |
|
Specialty Care |
$60 per visit |
|
|
Inpatient Services |
Tier 1 Hospital
(contracted, within the Service Area) |
$250 per day per admission
($1,000 max per admission) |
|
Tier 2 Hospital
(contracted, outside the Service Area) |
30% of the allowable amount
after deductible |
|
| Emergency Care Services |
Emergency Room |
$150 per visit |
| Urgent Care or Minor Emergency |
$50 per visit |
For more detailed information visit the plan documents:
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