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Medical Deductible, Individual $6,400 Combined Med/Rx N/A $750 $3,300 $5,350 $2,925
Medical Deductible, Family tooltip $12,800 Combined Med/Rx N/A $1,500 $6,600 $10,700 $5,850
Rx Deductible, Individual Included in Medical deductible N/A N/A $400 (Ded applies to Tiers 3 and 4) $400 (Ded applies to Tiers 3 and 4) N/A
Rx Deductible, Family tooltip Included in Medical deductible N/A N/A $800 (Ded applies to Tiers 3 and 4) $800 (Ded applies to Tiers 3 and 4) N/A
OOPM, Individual $7,900 $1,400 $2,600 $6,300 $7,900 $5,000
OOPM, Family tooltip $15,800 $2,800 $5,200 $12,600 $15,800 $10,000
Emergency Room - Applies to facility charges only tooltip 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Urgent Care $75 $10 $20 $50 $50 $35
Office Visit - Preventive Care tooltip No Charge No Charge No Charge No Charge No Charge No Charge
Office Visit - Primary Care $35 $0 $10 $20 $30 $10
Office Visit - Specialty Care $80 (after ded) ▲ $15 $30 $60 $75 $50
Office Visit - Other Practitioner Care $35 $0 $10 $20 $30 $10
Habilitative Services ‡ 40% (after ded) ▲ $15 $30 $60 $75 $50
Rehabilitative Services ‡ tooltip 40% (after ded) ▲ $15 $30 $60 $75 $50
Mental / Behavioral Health Services $35 $0 $10 $20 $30 $10
Substance Abuse Services $35 $0 $10 $20 $30 $10
Dental Services Related to Accidental Injury 40% (after ded) ▲ 10% 20% 30% 30% 20%
Family Planning No Charge No Charge No Charge No Charge No Charge No Charge
Pediatric Vision tooltip No Charge No Charge No Charge No Charge No Charge No Charge
Outpatient Professional & Facility tooltip 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Specialized Scanning Services (CT/PET Scan, MRI) 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Radiology Services (X-rays) $80 (after ded) ▲ $10 $30 $65 $75 $35
Laboratory Tests $40 (after ded) ▲ $10 $10 $40 $40 $15
Mental / Behavioral Health / Substance Abuse tooltip 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Cancer Chemotherapy and Other Provider-Administered Drugs -- Outpatient Setting tooltip 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Medical / Surgical tooltip 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Maternity tooltip 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Mental / Behavioral Health tooltip 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Substance Abuse tooltip 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Cancer Chemotherapy and Other Provider-Administered Drugs -- Inpatient Setting tooltip 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Skilled Nursing Facility tooltip 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Hospice No Charge No Charge No Charge No Charge No Charge No Charge
Tier-1: Lower-Cost Generic and Brand Name Drugs $20 $2 $5 $10 $20 $10
Tier-2: Preferred Generic and Brand Name Drugs 40% (after ded) ▲ $15 $30 $60 $60 $50
Tier-3: Non-Preferred Brand Name Drugs 50% (after ded) ▲ 20% 30% 40% (after Rx ded) ▲ 40% (after Rx ded) ▲ 30%
Tier-4: Generic and Brand Name Specialty Drugs 50% (after ded) ▲ 20% 30% 40% (after Rx ded) ▲ 40% (after Rx ded) ▲ 30%
Tier-5: Preventive Drugs No Charge No Charge No Charge No Charge No Charge No Charge
Durable Medical Equipment No Charge (after ded) ▲ No Charge No Charge (after ded) ▲ No Charge (after ded) ▲ No Charge (after ded) ▲ No Charge (after ded) ▲
Home Infusion tooltip No Charge (after ded) ▲ No Charge No Charge No Charge No Charge No Charge
Home Healthcare tooltip No Charge (after ded) ▲ No Charge No Charge No Charge No Charge No Charge
Emergency Medical Transportation (Ambulance) 40% (after ded) ▲ 10% 20% 30% 30% 20%
Dialysis Servicestooltip $80 (after ded) ▲ $15 $30 $60 $75 $50

Notes:

Green highlighting indicates that no Ded applies

▲Ded Applies. Ded is waived, except where indicated

Outpatient Habilitation & Rehabilitation configuration note: Member cost-share and visit limits shown apply in any place of service

§ Mail-order Rx drugs for tiers 1, 2, 3, and 5. For mail-order Rx, up to a 90-day supply is provided at twice the 30-day retail cost-sharing amount.

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