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 |
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 |