| Benefit |
Family Income Less Than 150% FPL
|
Family Income Between 150% and 250% FPL
|
| Annual Deductible |
None |
| Preexisting Condition Requirement |
None |
| Physician Office Visit |
$5 copay (primary care physician or specialist) |
$15 copay (primary care physician); $20 copay (specialist) |
| Hospital Care |
$5 per admission (waived if readmitted within 48 hours for same episode) |
$100 per admission (waived if readmitted within 48 hours for same episode) |
| Prescription Drug Copay |
$1 generic; $3 preferred brand; $5 non-preferred brand |
$5 generic; $20 preferred brand; $40 non-preferred brand |
| Maternity |
$5 copay OB or specialist, first visit only; $5 hospital admission |
$15 copay OB, first visit only; $20 copay specialist; $100 hospital admission |
| Routine Health Assessment and Immunizations |
No copays for services rendered under American
Academy of Pediatrics guidelines |
| Emergency Room |
$5 copay per use (waived if admitted); $10 copay per use for non-emergency |
$50 copay per use (waived if admitted) |
| Chiropractic Care |
$5 copay (maintenance visits not covered when no additional progress is apparent or expected to occur) |
$15 copay (maintenance visits not covered when no additional progress is apparent or expected to occur) |
| Ambulance Service (air and ground) |
No copay (100% of reasonable charges when deemed medically necessary by claims administrator) |
| Lab and X-ray |
No copay - 100% benefit |
| Physical, Speech and Occupational Therapy |
$5 copay per visit (limit of 52 visits per year per type of therapy) |
$15 copay per visit (limit of 52 visits per year per type of therapy) |
| Inpatient Mental Health Treatment (pre-authorization required) |
$5 copay per admission |
$100 copay per admission |
| Inpatient Substance Abuse Treatment (pre-authorization required) |
$5 copay per admission |
$100 copay per admission |
| Outpatient Mental Health and Substance Abuse Treatment (pre-authorization required) |
$5 copay per session |
$20 copay per session |
| Dental |
$5 copay per visit; no copay for routine preventive oral exam, x-rays, cleaning and fluoride application) |
$15 copay per visit; no copay for routine preventive oral exam, x-rays, cleaning and fluoride application |
| Vision Care |
$5 copay for prescription lenses and frames OR contact lenses; no copay for preventive annual exam and glaucoma testing |
$15 copay for prescription lenses and frames OR contact lenses; no copay for preventive annual exam and glaucoma testing |
| Annual Out-of-Pocket Maximums |
5% of annual family income |
