Plan Cost Summary
Estimated Monthly premium  
Calendar year deductible $6,650 per individual / $13,300 per family
Calendar year pharmacy deductible N/A
Calendar year out-of-pocket maximum $6,650 per individual / $13,300 per family

  

No cost preventive care
Preventive Care $0
Well Baby Care $0
Prenatal Office Visits $0
Pediatric Dental Benefits: Preventive $0
Pediatric Vision Benefits: Exams $0

 

No cost extras
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 (generic drugs) Before pharmacy deductible:
Full cost

 

After pharmacy deductible:
$0
Tier 2 (preferred brand drugs) Before pharmacy deductible:
Full cost

 

After pharmacy deductible:
$0
Tier 3 (non-preferred brand drugs) Before pharmacy deductible:
Full cost

 

After pharmacy deductible:
$0
Tier 4 (specialty drugs) Before pharmacy deductible:
Full cost

 

After pharmacy deductible:
$0

 

Physician and medical services
Office Visit - Primary Care (internal medicine, family practice, OB/GYN, pediatrics) Before deductible:
Full cost
  After deductible:
$0
Office Visit - Specialist Care Before deductible:
Full cost
  After deductible:
$0
Teladoc 0% after deductible
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) Before deductible:
Full cost
  After deductible:
$0
Chiropractic (from an American Specialty Health Plans network chiropractor) Not covered

 

Lab and X-ray diagnostics
Laboratory Tests Before deductible:
Full cost
  After deductible:
$0
X-rays Before deductible:
Full cost
  After deductible:
$0
Imaging (CT / PET scan, MRI) from an outpatient radiology center Before deductible:
Full cost
  After deductible:
$0

 

Urgent and emergency
Urgent care Before deductible:
Full cost
  After deductible:
$0
Emergency Room Services Before deductible:
Full cost
  After deductible:
$0
Ambulance Before deductible:
Full cost
  After deductible:
$0

 

Maternity care
Maternity - Prenatal office visits $0
Maternity - Other professional services Before deductible:
Full cost
  After deductible:
$0
Maternity - hospital stay Before deductible:
Full cost
  After deductible:
$0

 

Hospital and outpatient
Outpatient Surgery Services Before deductible:
Full cost
  After deductible:
$0
Hospital Stays Before deductible:
Full cost
  After deductible:
$0

 
 

Dental and vision
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