Calendar year deductible	$800 per individual / $1,600 per family
Calendar year pharmacy deductible	$25 per individual / $50 per family
Calendar year out-of-pocket maximum	$3,000 per individual / $6,000 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 pharmacy deductible:
	Tiers 1-4 = Full cost
	After pharmacy deductible:
	Tier 1 = $5
	Tier 2 = $25
	Tier 3 = $45
	Tier 4 = 15% up to $250 per prescription

Office Visit - Primary Care (internal medicine, family practice, OB/GYN, pediatrics)	$15
Office Visit - Specialist Care	$25
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)	$15
Chiropractic (from an American Specialty Health Plans network chiropractor)	Not covered

Laboratory Tests	$20
X-rays	$40
Imaging (CT / PET scan, MRI) from an outpatient radiology center	$100

Urgent care	$15
Emergency Room Services	$150
Ambulance	$75

Maternity - Prenatal Office Visits	$0
Maternity - Other professional services	25%
Maternity - hospital stay	Before deductible:
	Full cost
	After deductible:
	25%

Outpatient Surgery Services	15%
Hospital Stays	Before deductible:
	Full cost
	After deductible:
	25%

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