| COVERAGE | PREMIUMS |
|---|---|
| Individual (IND) | 300 |
| Individual + Spouse | 450 |
| Individual + Dependent(s) | 375 |
| Family (FAM) | 600 |
| PREVENTIVE CARE COVERAGE | INCLUDED |
|---|---|
| Office Visits: Adults Routine Physical | Yes |
| Office Visits: Routine Gynecological Exam | N/A |
| Office Visits: Well child care | N/A |
| Office Visits: All other visits to Primary Care | No |
| Office Visits: Specialist | No |
| PRESCRIPTION DRUG COVERAGE | INCLUDED |
|---|---|
| Brand Prescription Drugs | Inpatient Rx- Covered: Outpatient- Not Covered |
| Non- Formulary Prescription Drugs | Inpatient Rx- Covered: Outpatient- Not Covered |
| Mail Order for Prescription Drugs | Inpatient Rx- Covered: Outpatient- Not Covered |
| Family (FAM) | N/A |
| HOSPITAL SERVICES COVERAGE | AMOUNT |
|---|---|
| Emergency Room | 20% Coinsurance after deductible. Extra $50 deductible applies for Sickness if not admitted |
| Outpatient Lab/X-Rays | 40% Coinsurance after deductible. |
| Outpatient Surgery | 60% Coinsurance after deductible. |
| Hospitalization | 80% Coinsurance after deductible. |