| GOLD DEDUCTIBLE PLANS w/Rx |
$500 |
$1000 |
| Features |
| Deductible (individual/family) |
$500/$1,500 |
$1,000/$3,000 |
| Out-of-pocket maximum (individual/family) |
$1,500/$4,500 |
| Lifetime maximum |
$2 million |
| Benefits |
Services not subject to deductible unless otherwise indicated |
| Preventive Care |
| Immunizations |
No charge |
| Routine physicals |
$25 copay |
| Well-baby visits |
| Gynecholgical exams |
| Mammograms |
20% coinsurance |
| Outpatient services (per visit or procedure) |
| Primary care office visit |
$25 copay |
| Specialty care office visit |
$25 copay |
| Nurse treatment visit (includes allergy injections)1 |
20% coinsurance (after deductible) |
| Outpatient surgery |
20% coinsurance (after deductible) |
| Lab tests & X-rays |
20% coinsurance (after deductible) |
| Inpatient hospital care |
| Inpatient care |
20% coinsurance (after deductible) |
| Maternity coverage |
| Inpatient care |
20% coinsurance (after deductible) |
| Prenatal |
$25 copay per visit |
| First postpartum visit |
$25 copay (after deductible) |
| Emergency & urgent care |
| Emergency Department visit |
20% coinsurance (after deductible) |
| Urgent care visit |
$45 copay |
| Ambulance Service |
20% coinsurance |
| Prescription drugs |
| Pharmacy (up to a 30-day supply) |
$15 or 50%
(whichever is greater) |
| Other services |
| Vision exams |
$25 copay (after deductible) |
| Vision hardware allowance (applies to lenses, frames, and/or contacts every 24 months) |
$100 allowance |
Assurant Health
