Insurance Provider |
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Accident Death & Disability, Accident Medical Expenses, and Sickness Medical Expenses total to less than $250,000
|
Accident Death & Disability, Accident Medical Expenses, and Sickness Medical Expenses total to less than
$250,000 |
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|
Medical Calendar Year Deductible (Individual/Family)
None
|
Medical Calendar Year Deductible (Individual/Family)
None |
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Annual Out-of-Pocket Maximum
$3,000/$6,000
|
Annual Out-of-Pocket Maximum
$0 |
Outpatient
care
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Office visits: $20 copay
|
$0 |
Maternity/Prenatal Care2:
$15 copay
|
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Vaccines (immunizations):
No charge: $5 copay
|
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Allergy injections: $20 copay
|
º¸»ó °¡´ÉÇÔ $0 copay
(±â¿ÕÁõÀº º¸»ó¾ÈµÊ) |
MRI, CT and PET: $50 copay
|
$0 |
Outpatient surgery:
$250 copay per procedure
|
$0 |
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Emergency department visits (waived if admitted directly to hospital): $150 copay
|
$0 |
Ambulance services:
$150 copay
|
$0 |
Prescriptions
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Generic MOI (up to a 100-day supply): $20 copay
|
$0 |
Prescriptions
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Brand (up to a 30-day supply):
$30 copay |
$0 |
Brand MOI (up to a 100-day supply):
$60 copay
|
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Student : $1,620
Student and Spouse:
$3,566
Student and Child(ren):$3,241 |
Çлý: ¾à$492
¹è¿ìÀÚ:¾à$492
ÀÚ³à: ¾à$492 |