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Short Term Care: Services
| In-Network | Out-of-Network | |
|---|---|---|
|
COINSURANCE |
Plan pays: 80% Your responsibility: 20% |
Plan pays: 60% Your responsibility: 40% |
|
TELADOC |
$0 copayment per visit |
Not covered. |
| PRESCRIPTION DRUG COVERAGE Generic and brand name prescriptions. |
Plan pays: 80% Your responsibility: 20% |
Plan pays: 60% Your responsibility: 40% |
FOOTNOTES
1 Deductible per member per benefit period. Benefit periods are 90 days and 180 days
2 When the applicable out-of-pocket maximum for in-network provider services is reached, 100% of the maximum allowable charge is payable for other covered services received from an in-network provider during the remainder of the benefit period.