| |
Silver $500 with Rx |
Silver $1,000 with Rx |
Silver $2,500 with Rx |
Annual deductible
(per calendar year) |
$500 individual
$1,500 family |
$1,000 individual
$3,000 family |
$2,500 individual
$7,500 family |
Annual out-of-pocket maximum
(per calendar year) |
$1,500 individual
$4,500 family |
$2,500 individual
$7,500 family |
$7,500 individual
$22,500 family |
| Lifetime benefit maximum |
$2 million |
$2 million |
$2 million |
Hospital inpatient care
All inpatient care including lab and X-ray are covered
after payment of applicable coinsurance. There are no
limits on prescribed hospital stays. |
20% coinsurance
(after deductible) |
20% coinsurance
(after deductible) |
20% coinsurance
(after deductible) |
Office visits (primary and specialty)
Diagnosis and treatment by primary care providers,
consultation and treatment by specialists, routine
physical and hearing exams |
$25 per visit 1
(not subject to the deductible) |
20% coinsurance per visit 1
(not subject to the deductible) |
20% coinsurance per visit 1
(after deductible) |
Outpatient prescription drugs
When prescribed by a Participating Provider or a licensed
dentist in accordance with our formulary process |
$15 generic/$30 brand-name 2
(up to a 30-day supply)
Mail-order: two copays for up to
a 90-day supply |
50% coinsurance 2 (up to $150 maximum
for up to a 30-day supply)
Mail-order: two times maximum for
up to a 90-day supply |
50% coinsurance 2
(up to a 30-day supply)
$3,000 calendar-year benefit
maximum per individual |
| Outpatient lab and X-ray |
20% coinsurance 3
(after deductible) |
20% coinsurance 3
(after deductible) |
20% coinsurance 3
(after deductible) |
Emergency care
Within and outside our service area |
20% coinsurance 4
(after deductible) |
20% coinsurance 4
(after deductible) |
20% coinsurance 4
(after deductible) |
| Pregnancy Services |
| Prenatal care |
$25 copay per visit
(not subject to deductible) |
$25 copay per visit
(not subject to deductible) |
Not covered 5 |
Labor and delivery
(all necessary Participating Provider
and hospital services) |
20% coinsurance
(after deductible) |
20% coinsurance
(after deductible) |
Not covered 5 |
| Postpartum care |
$25 copay per visit
(after deductible) |
$25 copay per visit
(after deductible) |
Not covered 5 |
The deductible is waived for the following services: immunizations (children, adults, travel), well-baby visits,
prenatal visits, Pap test (any type), screening prostate-specific antigen (PSA) test, cholesterol test (lipid panel, all
types), fecal occult test, glucose test, chlamydia test, mammography, bone densitometry, flexible sigmoidoscopy,
colonoscopy.
- Well-baby visits (0 through 2 years) not subject to deductible
- Prescription drugs not subject to the deductible. Mail-order is available for maintenance drugs only.
- Deductible waived for certain preventive procedures and tests
- Coinsurance not waived if admitted to hospital
- Pregnancy complications covered as any other illness
|
Asuris
NW Health
