| Benefits | |
|---|---|
| Deductible | |
| Out of Pocket Maximum | |
| Coinsurance | |
| HSA Eligible | |
| Primary Care Physician Office Visit | |
| Specialist Office Visit | |
| VirtualCare PCP visit (Delivered via the Capital Blue Cross Virtual Care platform) | |
| Emergency Room | |
| Urgent Care | |
| Diagnostic lab services | |
| Out Patient Diagnostic Test | |
| Out Patient High Tech Imaging | |
| Out Patient Surgery Service | |
| In Patient Hospital Admission | |
| Retail Rx | |
| Home Delivery RX | |
| Formulary | |
| Disclaimer |
| Benefits | |
|---|---|
| Deductible | |
| Out of Pocket Maximum | |
| Routine Dental Checkup | |
| Diagnostic and preventative services | |
| Basic services | |
| Major services | |
| Orthodontia services |
| Benefits | |||||
|---|---|---|---|---|---|
| Routine eye exam | |||||
| Eyeglass Lenses | |||||
| Frames | |||||
| Contact Lenses | |||||
| Other add-ons | |||||
|
2Discounts are not insurance and create no liability for payment by the plan. ^You are responsible for frame costs over the allowance, minus a 30 percent discount. The scheduled amounts shown are the maximum allowable amounts. There is no assurance that the scheduled amount will be sufficient to pay the full cost of the service rendered or the materials selected. *You are responsible for contact lens costs over the allowance, minus a 25 percent discount. The scheduled amounts shown are the maximum allowable amounts. There is no assurance that the scheduled amount will be sufficient to pay the full cost of the service rendered or the materials selected. |
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