FirstCare LCOC Health Plan A-Low Summary

Health Plan A-Low
Covered Services		Member Responsibility
Lifetime Maximum Benefit		$750,000
Contract Year Deductible		$1,000 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	Inpatient Admissions including: Skilled Nursing Facility Chemical Dependancy Treatment Facility Psychiatric Hospital Rehablilitation Facility	$250 per day per admission $1,000 max per admission

Emergency Care Services	Emergency Room	$150 per visit
	Urgent Care or Minor Emergency	$50 per visit
	Ambulance	$150 per trip

For more detailed information visit the plan documents: Benefit Summary Prescription Drug Benefit

For more detailed information visit the plan documents: