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Annual Deductible : |
$1,500 |
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Coinsurance : |
You pay 0%, after annual deductible |
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Annual Out-of-Pocket Maximum (includes deductible) : |
$1,500 |
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Lifetime Maximum : |
$5 million per member |
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Office Visits : |
You pay $40 Copay |
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Professional Service Includes X-ray and lab charges : |
No Cost To You (after deductible) |
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Emergency Care : |
You pay $100 |
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Ambulance : |
You pay $100 |
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Hospital Inpatient Services : |
No Charge To You (after deductible) |
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Outpatient Services : |
No Charge To You (after deductible) |
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Preventive Care – Child : |
$40 Copay |
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Preventive Care – Adults : |
$40 Copay |
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Dental Care : |
$0 for cleanings, exams and x-rays. You pay 20% for minor restorative procedures like fillings after $25 deductible. $500/year maximum benefit. |
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Vision Care : |
We will pay $50 toward a routine eye exam, glasses or contact lenses and you’ll pay the rest. Not subject to the medical deductible. |
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Prescription Drug Benefits : |
You pay $10. Generic only coverage |
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Maternity : |
Not Covered |
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