|
|
| Shield Spectrum Savings 2400 Single |
In-Network |
Out-Of-Network |
 |
Annual Deductible |
Individual: $2,400 |
Individual: $2,400 |
|
Annual Out-Of-Pocket Limit |
Individual: $3,200 |
Individual: $3,200 |
|
Lifetime Maximum |
$6,000,000 |
$6,000,000 |
|
Office Visits |
30% |
50% |
|
Prescription Drugs |
30% |
30% |
|
Laboratory and Radiology |
30% |
50% |
|
Annual Physical Exam |
$35 |
Not Covered |
|
Annual OB-GYN Exam |
$35 |
Not Covered |
|
Prenatal / Postnatal Maternity |
Not Applicable |
Not Applicable |
|
Well Baby Care |
$35 |
Not Covered |
|
Outpatient Surgery |
30% |
50% ($300 maximum benefit per day) |
|
Emergency Room |
$75 (waived if admitted), then 30% |
$75 (waived if admitted), then 30% |
|
Ambulance |
30% |
30% |
|
Home Health Care |
30% (90 visits per year) |
Not Covered |
|
Mental Health Services |
30% (20 visits per year) |
Not Covered |
|
Chiropractic Care |
50% up to $25 (maximum benefit $25, 12 visits per year) |
Not Covered |
|
Acupuncture / Acupressure |
25% MyLifePath Discount |
Not Covered |
|
Inpatient Co-payment |
30% |
50% ($300 maximum benefit per day) |
| |
Maternity Care |
30% |
50% ($300 maximum benefit per day) |
|
Inpatient Mental Health |
30% |
50% ($300 maximum benefit per day) |
|
Chemical Dependency |
30% |
50% ($300 maximum benefit per day) |
|
| |
|
QUOTE
APPLY ONLINE
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DOCTOR SEARCH
PLAN
BENEFITS PDF
EXCLUSIONS |
| |
|
|
Individual Family