| Services | Gold Plan 1 |
|---|---|
| Value Basics | |
| Teladoc Virtual Care Visits 24/7/365 | FREE |
| Annual Wellness Visit ? Adults | FREE |
| Routine Preventive Screenings ? Children & Adults | FREE |
| Routine Vision Exams & eyewear for Children (0-18) | FREE |
| Preventive Prescription Drugs | FREE |
| 24 Hour Nurse Line | FREE |
| Urgent Care at Same Cost as Primary Physician Visit | YES |
| Plan Options with Adult Vision Services | YES |
| Benefit & Cost Share Highlights | |
| Deductible (Ind/Fam) | $2,100 / $4,200 |
| Out-of-Pocket Max (Ind/Fam) | $8,550 / $17,100 |
| Drug Deductible (Ind/Fam) | Combined Med/Rx Rx Tiers 3&4 Only |
| Emergency Room Services | 20% after ded |
| Hospital / Facility Services | |
| Inpatient Hospital | 20% after ded |
| Skilled Nursing Facility Services | 20% after ded |
| Hospital Physician Services | 20% after ded |
| Outpatient Surgery Services | 20% after ded |
| Outpatient Services | |
| Primary & Urgent Care Services | $10 |
| Specialist Services | $50 |
| Mental/Behavioral Health Services | $10 |
| Imaging & Specialized Radiology | 20% after ded |
| Rehabilitative Services -ST, OT, PT | $50 |
| Routine Laboratory Services | $15 |
| Routine X-Ray & Diagnostic Services | 20% after ded |
| Prescription Drugs | |
| Tier 1 ? Preferred Generic Drugs | $10 |
| Tier 2 ? Preferred Brand Drugs | $50 |
| Tier 3 ? Non-Pref Brand & Generic Drugs | 30% after ded |
| Tier 4 ? Specialty Drugs | 30% after ded |
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