Calendar year deductible	$6,300 per individual / $12,600 per family
Calendar year pharmacy deductible	$500 per individual / $1,000 per family
Calendar year out-of-pocket maximum	$8,200 per individual / $16,400 per family

Preventive Care	$0
Well Baby Care	$0
Prenatal Office Visits	$0
Pediatric Dental Benefits: Preventive	$0
Pediatric Vision Benefits: Exams	$0

24/7 Nurse Hotline	No additional cost
Shield Concierge	Not available
Health and Wellness Discounts (gym, weight loss programs, and more)	No additional cost

Retail Prescription Drugs	Before deductible:
	Tiers 1-4 = Full cost
	After pharmacy deductible:
	Tier 1 = $18
	Tiers 1-4 = 35% up to $250 per prescription

Office Visit - Primary Care (internal medicine, family practice, OB/GYN, pediatrics)	Before deductible:
	Visits 1-3 = $65
	Visits 4+ = Full cost
Office Visit - Specialist Care	After deductible:
	$65
Teladoc	Before deductible:
	Visits 1-3 = $95
	Visits 4+ = Full cost
Retail clinics	After deductible:
	$95
Acupuncture (from an American Specialty Health Plans network acupuncturist)	$0
Chiropractic (from an American Specialty Health Plans network chiropractor)	Cost depends on the service performed. Cost is the same as if the service was performed elsewhere.
	Before deductible:
	Visits 1-3 = $65
	Visits 4+ = Full cost
	After deductible:
	$65
	Not covered

Laboratory Tests	Before and after deductible:
	$40
X-rays	Before deductible:
	Full cost
Imaging (CT / PET scan, MRI) from an outpatient radiology center	After deductible:
	40%
	Before deductible:
	Full cost
	After deductible:
	40%

Urgent care	Before deductible:
	Visits 1-3 = $65
	Visits 4+ = Full cost
Emergency Room Services	After deductible:
	$65
Ambulance	Before deductible:
	Full cost
	After deductible:
	40%
	Before deductible:
	Full cost
	After deductible:
	40%

Maternity - Prenatal Office Visits	$0
Maternity - Other professional services	Before deductible:
	Full cost
Maternity - hospital stay	After deductible:
	40%
	Before deductible:
	Full cost
	After deductible:
	40%

Outpatient Surgery Services	Before deductible:
	Full cost
Hospital Stays	After deductible:
	40%
	Before deductible:
	Full cost
	After deductible:
	40%

Pediatric Dental Benefits: Preventive	$0
Pediatric Dental Benefits: Restorative Procedures	20%
Pediatric Dental Benefits: Medically Necessary Orthodontics	50%
Pediatric Vision Benefits: Exams	$0
Pediatric Vision Benefits: Eye Glasses	1 pair per year