TRADITIONAL HEALTH PLAN (THP)
IN-NETWORK BENEFITS
ANNUAL DEDUCTIBLE
$2,000 individual / $4,000 family
ANNUAL OUT-OF-POCKET MAXIMUM
$5,500 individual / $11,000 family
IN-NETWORK COPAYS
TELADOC
$0
PRIMARY CARE OFFICE VISIT SPECIALIST OFFICE VISIT
$45
$60
URGENT CARE (CLINIC)
$70
OFFICE VISIT DIAGNOSTIC X-RAY & LABS
$0 after copay
HEARING AIDS (ONE PER YEAR, PER EAR, EVERY 3 YEARS)
$0 ($5,000 maximum for 18+)
IN-NETWORK PHYSICIAN SERVICES
OFFICE SERVICES (X-RAYS, LABS, SURGERIES)
included in copay
ALLERGY INJECTIONS
$0
ROUTINE/PREVENTIVE CARE
$0
ROUTINE GYNECOLOGICAL CARE AND/OR MAMMOGRAMS
$0
CARDIAC STRESS TEST
$0
IN-NETWORK HOSPITAL SERVICES
EMERGENCY ROOM CARE
$500
INPATIENT HOSPITAL SERVICES
20% after deductible
OUTPATIENT DIAGNOSTIC HIGH-TECH RADIOLOGY
OUT-OF-NETWORK BENEFITS
ANNUAL DEDUCTIBLE
$4,000 individual / $8,000 family
ANNUAL OUT-OF-POCKET MAXIMUM COST TO USE PROVIDERS/FACILITIES
$11,000 individual / $22,000 family
40% after deductible
PRESCRIPTION BENEFITS
RETAIL PRESCRIPTION (30-DAY SUPPLY) CERTAIN PREVENTIVE GENERICS SEE INSIDEAVERITT.COM FOR THE FULL LIST
$0 copay
GENERIC
$20 copay
PREFERRED BRAND, INCLUDING SPECIALTY NONPREFERRED BRAND, INCLUDING SPECIALTY
$40 copay
$80 copay
RETAIL OR MAIL ORDER PRESCRIPTION (90-DAY SUPPLY) CERTAIN PREVENTIVE GENERICS SEE INSIDEAVERITT.COM FOR THE FULL LIST
$0 copay
GENERIC
$40 copay
PREFERRED BRAND
$80 copay
NONPREFERRED BRAND $160 copay This is a summary of your coverage only. In-network services are based on negotiated charges; out-of-network services are based on reasonable and customary (R&C) charges.
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