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Contact Information

Toll-Free Phone: Current Members: 1-866-572-9396 Non-members: 1-800-647-7328
TTY/TDD Phone: Current Members: 711 or 1-888-685-8480 Non-members: 1-800-387-1074
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Benefit Summary

Annual Costs 2010 Coverage

Annual deductible

$0

Annual out-of-pocket maximum

$750/person

Annual prescription drug deductible

Does not apply

Medical Benefits 2010 Coverage

Ambulance services

 

(air)

$50/trip

(ground)

$50/trip

Diagnostic tests, laboratory, and X-rays

Enrollee pays $0

Durable medical equipment, supplies, and prostheses

Enrollee pays $0

Emergency room (copay waived if admitted)

$50

Hearing

 

(routine annual exam)

$10

(hardware)

Enrollee pays any amount over $800 every 36 months for hearing aid and rental/repair combined

Hospital services

 

(inpatient)

$150/day for 1-4 days

(outpatient)

Enrollee pays $0

Mental health care

 

(outpatient)

$10

Obstetric care

 

(inpatient)

Information unavailable, contact your plan

(outpatient)

Information unavailable, contact your plan

Office visits

$10

Physical, occupational, and speech therapy (per-visit cost for 60 visits/year combined)

$10

Prescriptions

 

tier 1 (retail pharmacy, 30-day supply)

$10

tier 2 (retail pharmacy, 30-day supply)

$25

tier 3 (retail pharmacy, 30-day supply)

$40

tier 1 (mail order, 90-day supply)

$20

tier 2 (mail order, 90-day supply)

$50

tier 3 (mail order, 90-day supply)

$80

Preventive care

Enrollee pays $0

Spinal manipulations (per-visit cost for 10 visits/year)

$10

Vision care

 

(annual exam)

$10

(glasses and contact lenses)

Any amount over $150 every 12 months