Choice Silver Standard POS
What is the family plan deductible
$8600 per family
What is the cost for Tier 1 Pharmacy Drugs?
$10 copayment per prescription
What is the Out of pocket maximum for Out of Network provider for family?
$24,000 per family
How much is the individual plan deductible?
$1300 member
What is the Individual Deductible?
$6,500 per member
What is the Out-of-Pocket Maximum for Individual? (Includes deductibles, copayments and coinsurance)
$8,150 per member
$40 copayment per visit
How much is Laboratory services?
$15 copayment per service
What is the family out of pocket maximum?
$10500 per family
What is the Out-of-Pocket Maximum for Family?
$16,300 per family
How much is Mental Health and Substance Abuse Office Visits for out of network providers? (OON)
40% coinsurance per visit after OON plan deductible is me
Mental Health and Substance Abuse Office Visits Cost?
$40 copayment per visit
How much is a mammography ultrasound?
$50 copayment per service
How much is advance radiology(CT,PET scan, MRI)?
$65 copayment per service up to a combined annual maximum of $375 for MRI and CAT scans; $400 for PET scans
What is the cost for a MRI?
50% coinsurance per service after INET plan deductible is met
How much is Non-Advanced Radiology?
$40 copayment per service after INET plan deductible is met
What is the Cost for Speech Therapy?
$30 copayment per visit after INET plan deductible is met
What is the family deductible for the year?
$7,500 per family
You need to conduct a Mammography Ultrasound however your doctor is OON. What is the cost to perform it?
30% coinsurance per service after OON plan deductible is met
A member is required to pay full cost for Emergency room visit.
How much is the Diabetic Equipment and Supplies?
40% coinsurance per equipment/supply
What is the Cost for a CT/PET Scan, MRI?
$75 copayment per service after INET plan deductible met is up to a combined annual maximum of $375 for MRI and CAT scans; $400 for PET scans
What is the cost for the Adult/pediatric visits?
No cost
You need to access Chiropractic Services, however this is your 21st time for the year. What is the cost?
$40 copayment per visit
(20 visits per calendar year)
Prescription Eye Glasses Cost OON
Not Covered