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What's covered

Copays ?

Medical Services
Primary Care Physician $20.00
Specialist $20.00
Prescription Drugs
Primary Care Physician $20.00
Specialist $20.00
Primary Care Physician $20.00

Coinsurance ?

Once the deductible is met, your health plan pays 100% of a covered health care service.

Health Plan Pays 70%
You Pay 30%

What's Covered

Benefits Certificate

Benefit information includes out-of-pocket information for individuals and families. This information is as accurate and as up to date as possible. Recently submitted claims may not be processed.

Your plan may have other benefits not listed here. Refer to your plan's benefit document for a complete list.

The publication of this information is not a guarantee of coverage. The summary is based upon the information available at this time and is subject to the terms, conditions, exclusions and limitations of the Plan as set forth in the benefit certificate.