|
|
| Shield Spectrum 500 |
In-Network |
Out-Of-Network |
 |
Annual Deductible |
Individual: $500 Family: $1,000 |
Individual: $500 Family: $1,000 |
|
Annual Out-Of-Pocket Limit |
Individual: $3,500 Family: $7,000 (Deductible not included) |
Individual: $7,000 Family: $14,000 (Deductible not included) |
|
Lifetime Maximum |
$6,000,000 |
$6,000,000 |
|
Office Visits |
$30 |
50% |
|
Prescription Drugs |
$10 Generic $35 Brand Formulary ($50 or 50% whichever is greater Brand Non-Formulary $150 max copayment); $250 Brand Deductible |
$10 Generic $35 Brand Formulary ($50 or 50% whichever is greater Brand Non-Formulary $150 max copayment); $250 Brand Deductible |
|
Laboratory and Radiology |
25% |
50% |
|
Annual Physical Exam |
$30 |
Not Covered |
|
Annual OB-GYN Exam |
$30 |
Not Covered |
|
Prenatal / Postnatal Maternity |
Not Applicable |
Not Applicable |
|
Well Baby Care |
$30 |
Not Covered |
|
Outpatient Surgery |
25% plus $250 per visit |
50% ($250 maximum benefit per day) |
|
Emergency Room |
$100 (waived if admitted), then 25% |
$100 (waived if admitted), then 25% |
|
Ambulance |
25% |
25% |
|
Home Health Care |
25% (90 visits per year) |
Not Covered |
|
Mental Health Services |
25% (20 visits per year) |
Not Covered |
|
Chiropractic Care |
50% (deductible waived; maximum benefit $25 per visit, 12 visits per year) |
Not Covered |
|
Acupuncture / Acupressure |
25% MyLifePath Discount |
Not Covered |
|
Inpatient Co-payment |
25% plus $250 per admission |
50% ($250 maximum benefit per day) |
| |
Maternity Care |
25% plus $250 per admission |
50% ($250 maximum benefit per day) |
|
Inpatient Mental Health |
25% plus $250 per admission |
50% ($250 maximum benefit per day) |
|
Chemical Dependency |
25% plus $250 per admission |
50% ($250 maximum benefit per day) |
|
| |
|
QUOTE
APPLY ONLINE
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PLAN
BENEFITS PDF
EXCLUSIONS |
| |
|
|
Individual Family