18th of month Prior to Effective date
18-64
Available in All States
Dependents to age 26
$0 Copay | 100% Coverage for Mandated Preventative Services
Adults| Woman| ChildrenUnlimited
$0 Consult Fee
$0
$0
$0
$0
$0 Copay
(Limited to preventive only)
Tier 1 = $0 (Over 200 drugs)
Tier 2 = $10 (Or less)
Tier 3 = $25 (Over 600 drugs)
Tier 4 = $50 (Or less)
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
18th of month Prior to Effective date
18-64
Available in All States
Dependents to age 26
$0 Copay | 100% Coverage for Mandated Preventative Services
Adults| Woman| ChildrenUnlimited
$0 Consult Fee
$0
$8,150
$16,300
$0 Copay
(Limited to preventive only)
Tier 1 = $0 (Over 200 drugs)
Tier 2 = $10 (Or less)
Tier 3 = $25 (Over 600 drugs)
Tier 4 = $50 (Or less)
$35 Copay (Existing Doctor)
$70 Copay (New Doctor)
$75 Copay
(In?Network)
$75 Copay (Existing Doctor)
$150 Copay (New Doctor)
$75 Copay (Existing Doctor)
$150 Copay (New Doctor)
$5,000
(Limited to $1,000 per day;
maximum of 5 days)
$50 Copay
(Per panel tested / per image billed)
$500 Copay
(Per image tested)
N/A
N/A
N/A
N/A
N/A
N/A
18th of month Prior to Effective date
18-64
Available in All States
Dependent to age 26
$0 Copay | 100% Coverage for Mandated Preventative Services
Adults| Woman| ChildrenUnlimited
$0 Consult Fee
$0
$0
$8,150
$16,300
$0 Copay
(Limited to preventive only)
Tier 1 = $0 (Over 200 drugs)
Tier 2 = $10 (Or less)
Tier 3 = $25 (Over 600 drugs)
Tier 4 = $50 (Or less)
$25 Copay
(Limit of 8 visits per plan year)
$50 Copay
(Limit of 2 visits per plan year)
$50 Copay
(Limit of 8 visits per plan year)
N/A
N/A
$50 Copay
(Limited to 3 per plan year)
$350 Copay
(Limited to 1 per plan year)
$350 Copay Per Admission
(Limited to 5 days and 2 surgeries)
$350 Copay
(Limited to 1 visit per plan year)
$350 Copay
(Limited to 1 visit per plan year)
Outpatient: $25 Copay Per Day
Inpatient: $250 Copay Per Day
(Both limited to 5 days per plan year)
$25 Copay
(Limited to 10 visits per plan year)
N/A
18th of month Prior to Effective date
18-64
Available in All States
Dependent to age 26
$0 Copay | 100% Coverage for Mandated Preventative Services
Adults| Woman| ChildrenUnlimited
$0 Consult Fee
$0
$0
$5,000
$10,000
$0 Copay
(Limited to preventive only)
Tier 1 = $0 (Over 200 drugs)
Tier 2 = $10 (Or less)
Tier 3 = $25 (Over 600 drugs)
Tier 4 = $50 (Or less)
$15 Copay
(Limit of 10 visits per plan year)
$35 Copay
(Limit of 3 visits per plan year)
$25 Copay
(Limit of 10 visits per plan year)
N/A
N/A
$50 Copay
(Limited to 3 per plan year)
$350 Copay
(Limited to 2 per plan year)
$350 Copay Per Admission
(Limited to 7 days and 3 surgeries)
$350 Copay
(Limited to 2 visit per plan year)
$350 Copay
(Limited to 1 visit per plan year)
Outpatient: $25 Copay Per Day
Inpatient: $250 Copay Per Day
(Both limited to 7 days per plan year)
$25 Copay
(Limited to 10 visits per plan year)
$350 Copay
(Professional Services)
$350 Copay Per Admission
(Childbirth/Delivery)
* ExclusionsPLEASE NOTE: Please refer to the Schedule of Benefits for the official list of Benefits Coverage, Limitations, and Exclusions. If plan comparison differs from the Schedule of Benefits, the Schedule of Benefits will govern.