Plan Cost Summary
Estimated Monthly premium  
Calendar year deductible $9,200 per individual / $18,400 per family
Calendar year pharmacy deductible N/A
Calendar year out-of-pocket maximum $9,200 per individual / $18,400 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:
Visits 1-3 = $0
Visits 4+ = Full cost
  After deductible:
$0
Office Visit - Specialist Care Before deductible:
Full cost
  After deductible:
$0
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) Before deductible:
Visits 1-3 = $0
Visits 4+ = 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:
Visits 1-3 = $0
Visits 4+ = 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 Before deductible:
Full cost
  After deductible:
$0
Pediatric Dental Benefits: Medically Necessary Orthodontics Before deductible:
Full cost
  After deductible:
$0
Pediatric Vision Benefits: Exams $0
Pediatric Vision Benefits: Eye Glasses Before deductible:
Full cost
  After deductible:
1 pair per year