Preventive care |
Covered 100%, no deductible |
Covered 100%, no deductible |
Covered 100%, no deductible |
Covered 100%, no deductible |
Covered 100% |
Doctor's office visit |
You pay 25% after deductible |
You pay 25% after deductible |
You pay $30 for PCP visit and $50 for specialist visit, no deductible |
You pay $25 for PCP visit and $40 for specialist visit, no deductible |
You pay $25 for PCP visit and $40 for specialist visit |
Emergency room |
You pay 25% after deductible |
You pay 25% after deductible |
You pay $150, then 30% after deductible |
You pay 25% after deductible |
You pay $200 |
Urgent care |
You pay 25% after deductible |
You pay 25% after deductible |
You pay 30% after deductible |
You pay 25% after deductible |
You pay $50 |
Inpatient care |
You pay 25% after deductible |
You pay 25% after deductible |
You pay 30% after deductible |
You pay 25% after deductible |
You pay $350 |
Outpatient care |
You pay 25% after deductible |
You pay 25% after deductible |
If not an office visit, you pay 30% after deductible |
If not an office visit, you pay 25% after deductible
|
If not an office visit, covered 100%*** |