Calendar year deductible	$4,750 per individual / $9,500 per family
Calendar year pharmacy deductible	$30 per individual / $60 per family
Calendar year out-of-pocket maximum	$7,250 per individual / $14,500 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	Before deductible:
	Tiers 1-4 = Full cost
	After deductible:
	Tier 1 = $16
	Tier 2 = $55
	Tier 3 = $85
	Tier 4 = 20% up to $250 per prescription

Office Visit - Primary Care (internal medicine, family practice, OB/GYN, pediatrics)	$45
Office Visit - Specialist Care	$85
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)	$45
Chiropractic (from an American Specialty Health Plans network chiropractor)	Not covered

Laboratory Tests	$50
X-rays	$90
Imaging (CT / PET scan, MRI) from an outpatient radiology center	$325

Urgent care	$45
Emergency Room Services	$400
Ambulance	$250

Maternity - Prenatal Office Visits	$0
Maternity - Other professional services	30%
Maternity - hospital stay	Before deductible:
	Full cost
	After deductible:
	30%

Outpatient Surgery Services	20%
Hospital Stays	Before deductible:
	Full cost
	After deductible:
	30%

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