Office Visit Copay : $20.00
In-Network Deductible: $250.00
Co-Insurance In-Network: 90% after deductible has been meet
Co-Insurance Maximum In-Network: Pay 10% out of pocket expenses up to $1500.00
Emergency Room Copay: $75.00
Prescription Drug Program
Retail Copay Generic: $5.00
Retail Copay Regular: $20.00
Retail Copay High Cost Drugs: $35.00
This cost is based on a monthly basis therefore if you purchase a three month supply you will pay $15.00 for generic drugs, $60.00 for regular drugs and $105.00 for high cost drugs.
Mail In Copay Generic: $10.00
Mail In Copay Regular: $40.00
Mail in Copay High Cost Drugs: $70.00
This is the cost for a 3 months supply. Therefore, basically you buy 2 and get 1 for free.
Diagnostic and Preventive Care – 100% (2 free cleanings each year)
Basic Care – 80% (emergency pain relief, extractions, oral surgery, fillings, general anesthesia, treatment of disease of gums or related tissue, treatment of tooth pulp, including root canal therapy and pulp vitality test, injection of antibiotic drugs, repair of recementation of crowns, inlays, onlays, bridgework or dentures.)
Major Care – 50% (inlays, onlays, crowns and other Gold and baked porcelain restorations, initial installation of bridgework, initial installation of partial and full removable dentures, replacement of existing partial, full removable dentures, fixed bridgework by a new denture or new bridgework, the addition of teeth to an existing partial removable denture or bridgework.)
Orthodontic Care – 50% with a limiting age of 19. Maximum lifetime benefits - $1000.00
Pay $20.00 copay to receive eye exam from a Blue Cross Blue Shield provider.
Eye Glasses or contacts are totally up to you.