Calendar year deductible	$75 per individual / $150 per family
Calendar year pharmacy deductible	$0
Calendar year out-of-pocket maximum	$900 per individual / $1,800 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	Tier 1 = $3
	Tier 2 = $10
	Tier 3 = $15
	Tier 4 = 10% up to $150 per prescription

Office Visit - Primary Care (internal medicine, family practice, OB/GYN, pediatrics)	$5
Office Visit - Specialist Care	$8
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)	$5
Chiropractic (from an American Specialty Health Plans network chiropractor)	Not covered

Laboratory Tests	$8
X-rays	$8
Imaging (CT / PET scan, MRI) from an outpatient radiology center	$50

Urgent care	$5
Emergency Room Services	$50
Ambulance	$30

Maternity - Prenatal Office Visits	$0
Maternity - Other professional services	$10
Maternity - hospital stay	Before deductible:
	Full cost
	After deductible:
	10%

Outpatient Surgery Services	10%
Hospital Stays	Before deductible:
	Full cost
	After deductible:
	10%

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