Calendar year deductible	$9,100 per individual / $18,200 per family
Calendar year pharmacy deductible	N/A
Calendar year out-of-pocket maximum	$9,100 per individual / $18,200 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 deductible:
	Tiers 1-4: $0

Office Visit - Primary Care (internal medicine, family practice, OB/GYN, pediatrics)	Before deductible:
	Visits 1-3 = $0
	Visits 4+ = Full cost
Office Visit - Specialist Care	After deductible:
	$0
Teladoc	Before deductible:
	Full cost
Retail clinics	After deductible:
	$0
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 = $0
	Visits 4+ = Full cost
	After deductible:
	$0
	Not covered

Laboratory Tests	Before deductible:
	Full cost
X-rays	After deductible:
	$0
Imaging (CT / PET scan, MRI) from an outpatient radiology center	Before deductible:
	Full cost
	After deductible:
	$0
	Before deductible:
	Full cost
	After deductible:
	$0

Urgent care	Before deductible:
	Visits 1-3 = $0
	Visits 4+ = Full cost
Emergency Room Services	After deductible:
	$0
Ambulance	Before deductible:
	Full cost
	After deductible:
	$0
	Before deductible:
	Full cost
	After deductible:
	$0

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

Outpatient Surgery Services	Before deductible:
	Full cost
Hospital Stays	After deductible:
	$0
	Before deductible:
	Full cost
	After deductible:
	$0

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