Immunizations and Lead NONE NONE Screening for Children Second Surgical opinion NONE NONE Pre-natal visits NONE NONE Prescription Drugs [$250] [Generic Drugs] [$50] [Preferred Drugs] [$100] [Non-Preferred Drugs] [$150] [All other Covered Charges Per Covered Person $500 $1,500 Per Covered Family $1,000 $3,000] (Use above deductible for separate accumulation..) [All other Covered Charges Per Covered Person $1,000 $2,000 Per Covered Family $2,000 $4,000 (Use above if Tier 1 deductible can be satisfied independently; Tier 1 accumulates toward Tier 2) Copayment applies after the Cash Deductible is satisfied Preventive Care NONE NONE Primary Care Physician N/A See Tier 2 $30 Visits [when care is provided by the pre-selected PCP] $30 $50 Specialist Visits [and PCP visits if the PCP was not Pre-natal visits NONE NONE All Other Practitioner Visits N/A See Tier 2 $30 Hospital Confinement $300 per day up to $1500 per $500 per day up to $3000 per confinement; up to $3000 per confinement; up to $5000 per year year
Immunizations and Lead Screening for Children NONE NONE Second Surgical opinion Pre-natal visits NONE NONE NONE NONE Prescription Drugs [Generic Drugs] [Preferred Drugs] [Non-Preferred Drugs] [$250] [$50] [$100] [$150] [All other Covered Charges Per Covered Person Per Covered Family (Use above deductible for separate accumulation..) [All other Covered Charges Per Covered Person Per Covered Family (Use above if Tier 1 deductible can be satisfied independently; Tier 1 accumulates toward Tier 2) Copayment applies after the Cash Deductible is satisfied $500 $1,000 $1,000 $2,000 $1,500 $3,000] $2,000 $4,000 Preventive Care Primary Care Physician Visits [when care is provided by the pre-selected PCP] Specialist Visits [and PCP visits if the PCP was not Pre-natal visits All Other Practitioner Visits Hospital Confinement NONE N/A See Tier 2 $30 NONE N/A See Tier 2 $300 per day up to $1500 per confinement; up to $3000 per year NONE $30 $50 NONE $30 $500 per day up to $3000 per confinement; up to $5000 per year
policyb_e.docx