BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Combined Medical/Pharmacy Out- of-Pocket Maximum Combined Medical/Pharmacy Out- of-Pocket: includes retail and home delivery drugs Home Delivery Pharmacy Costs Contribute to the Combined Medical/Pharmacy Out-of-Pocket Maximum Physician’s Services Primary Care Physician’s Office Visit Specialty Care Physician’s Office Visits Consultant and Referral Physician’s Services Note: OB/GYN providers will be considered either as a PCP or Specialist, depending on how the provider contracts with the Insurance Company. Surgery Performed in the Physician’s Office
Yes
Yes
Yes
Yes
No charge after $30 per office visit copay No charge after $40 Specialist per office visit copay
50% after plan deductible
50% after plan deductible
No charge after the $30 PCP or $40 Specialist per office visit copay No charge after the $30 PCP or $40 Specialist per office visit copay No charge after either the $30 PCP or $40 Specialist per office visit copay or the actual charge, whichever is less
50% after plan deductible
Second Opinion Consultations (provided on a voluntary basis)
50% after plan deductible
Allergy Treatment/Injections
50% after plan deductible
Allergy Serum (dispensed by the Physician in the office)
No charge
50% after plan deductible
Medical Telehealth
No charge
In-Network coverage only
Preventive Care Routine Preventive Care - all ages
No charge
In-Network coverage only
Immunizations - all ages
No charge
In-Network coverage only
Mammograms, PSA, PAP Smear Preventive Care Related Services (i.e. “routine” services)
No charge
50% after plan deductible
Diagnostic Related Services (i.e. “non-routine” services)
Subject to the plan’s x-ray & lab benefit; based on place of service
Subject to the plan’s x-ray & lab benefit; based on place of service
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