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Health Plan D - Low |
|
Covered Services |
Member Responsibility |
| Lifetime Maximum Benefit |
$500,000 |
| Contract Year Deductible |
$30,000 per member |
|
|
Limited Physician Visits
No deductible |
Primary Care Physician
Limited to three visits per member per contract year with No Deductible |
$55 per visit |
|
|
Limited Inpatient Services
No Deductible
|
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
No Deductible |
|
| Emergency Care Services |
Emergency Room |
$500 per visit after deductible
Waived if admitted |
| Urgent Care or Minor Emergency |
$55 per visit after
deductible |
For more detailed information visit the plan documents:
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