Calendar year deductible	$0
Calendar year pharmacy deductible	$0
Calendar year out-of-pocket maximum	$8,550 per individual / $17,100 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	No additional cost
Health and Wellness Discounts (gym, weight loss programs, and more)	No additional cost

Retail Prescription Drugs	Tier 1 = $15
	Tier 2 = $60
	Tier 3 = $85
	Tier 4 = 20% up to $250 per prescription

Office Visit - Primary Care (internal medicine, family practice, OB/GYN, pediatrics)	$35
Office Visit - Specialist Care	$65
Teladoc	$0
Retail clinics	Cost depends on the service performed. Cost is the same as if the service was performed elsewhere.
Acupuncture (from an American Specialty Health Plans network acupuncturist)	$35
Chiropractic (from an American Specialty Health Plans network chiropractor)	Not covered

Laboratory Tests	$40
X-rays	$75
Imaging (CT / PET scan, MRI) from an outpatient radiology center	$75

Urgent care	$35
Emergency Room Services	$350
Ambulance	$250

Maternity - Prenatal Office Visits	$0
Maternity - Other professional services	$0
Maternity - hospital stay	$350 per day up to 5 days per admission

Outpatient Surgery Services	$150
Hospital Stays	$350 per day up to 5 days per admission

Pediatric Dental Benefits: Preventive	$0
Pediatric Dental Benefits: Restorative Procedures	$25
Pediatric Dental Benefits: Medically Necessary Orthodontics	$1,000
Pediatric Vision Benefits: Exams	$0
Pediatric Vision Benefits: Eye Glasses	1 pair per year