Child-Only Plans

BENEFITS
	PPO 30%
	In Network	Out of Network
Annual Deductible Deductible must be met before Coinsurance applies.	$1,000, $2,000, $2,500, $3,500, $5,000, $7,500, $10,000	$2,000, $4,000, $5,000, $7,000, $10,000, $15,000, $20,000
Coinsurance Out-of-Pocket Maximum	$4,500	$9,000
Preventive Care Services	$0	50%
Medical Office Visits
Non-Specialist	$25	50%
Specialist	$50	50%
Emergency Care	$200
Urgent Care	$50
Hospital Services
Inpatient & Outpatient	30%	50%
Acupuncture/Chiropractic
$1,500 Maximum per service, per year	30%	50%
Lifetime Maximum Benefit	Unlimited
Prescription Drug Benefits	Must use participating pharmacy
Generic	$10
Brand Name Preferred	$35
Brand Name Non-Preferred	$55
Specialty Medications	20%

This summary contains highlights only and is subject to change. The specific terms of coverage are listed in the Evidence of Coverage Handbook, including details on Limitations and Exclusions. Additionally, some services require Prior Authorization.