Details at a Glance
Plan TypeHMO
Office Visit for Primary Doctor$25 Copay
Office Visit for Specialist$25 Copay
Coinsurance None
Annual Deductible None
Separate Prescription
Drugs DeductibleNone Prescription Drugs Generic: $10 Copay (up to 30-day supply) Brand: $35 Copay (up to 30-day supply) Non-Formulary: Not Covered Annual Out-of-Pocket LimitIndividual:$2,500 Lifetime MaximumUnlimited Health Savings Account (HSA) EligibleNo Out-of-Network CoverageNo Out of Country Coverage Emergency Care Only Find Doctors (Search to see if your doctors are part of this plan's network.) Physicians
Primary Care Physician (PCP) RequiredYes Specialist Referrals RequiredYes Preventive Care Coverage
Periodic Health Exam$25 Copay Periodic OB-GYN Exam$25 Copay Well Baby CareNo Charge Prescription Drug Coverage
Generic Prescription Drugs Copay (up to 30-day supply) Brand Prescription Drugs Copay (up to 30-day supply) Non-Formulary Prescription Drugs Coverage Not Covered Mail Order for Prescription Drugs Generic: Copay Brand: Copay Non-Formulary: Not Covered Days Supply: 100 Separate Prescription Drugs DeductibleNone Hospital Services Coverage

Emergency Room$100 Copay (waived if admitted) Outpatient Lab/X-Ray$10 Copay Outpatient Surgery$100 Copay per procedure Hospitalization$200 Copay Per day Maternity Coverage
Pre & Postnatal Office VisitNo Charge Labor & Delivery Hospital Stay$200 Copay Per day Additional Coverage
Chiropractic CoverageNot Covered Mental Health Coverage$25 Copay Individual Visit / $12 Copay Group Visit, 20 Visits per year Additional Information
A.M. Best RatingA- as of 09/21/2007 Application Fee No Electronic Signature for Application Available Yes Will insurance company obtain and pay for medical records?N/A