|
Health Plan C 1M |
|
Covered Services |
Member Responsibility |
| Lifetime Maximum Benefit |
$1,000,000 |
| Contract Year Deductible |
$2,600 member coverage
$5,200 family coverage |
| Out-of-Pocket Maximum |
$5,000 member coverage
$10,000 family coverage |
|
| Doctor Office Visits
|
Primary Care Physician |
$25 per visit |
|
Specialty Care |
$55 per visit |
|
|
Inpatient Services
- Skilled Nursing Facility
- Chemical Dependancy Treatment Facility
- Psychiatric Hospital
- Rehablilitation Facility
|
Tier 1 Hospital
(contracted, within the Service Area) |
$300 per day per admission
|
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|
Tier 2 Hospital
(contracted outside the Service Area, and non-contracted) |
30% of the allowable amount per day after deductible |
|
|
| Emergency Care Services |
Emergency Room |
$150 per visit
waived if admitted |
| Urgent Care or Minor Emergency |
$55 per visit |
| Ambulance |
$150 per trip |
|
|
For more detailed information visit the plan documents:
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