Medical Benefit Features

Coverage

Premium

$307

Deductible

Varies*

Primary Care Office Visit

$25 co-pay

Specialist Office Visit

$35 co-pay

Preventive Care Office Visits

100% coverage, no co-pay

Emergency Room Visit

$100 (waived if emergency)

Prescription Medication

Three-tiered co-pay as low as $10, $7,500 annual benefit limit

Durable Medical Equipment

$4,000, no co-pay

Behavioral Health Services

$35/$25 co-pay (Please see the Charter Oak Behavioral Health website for details on co-pays)

Outpatient Rehabilitation

$35 co-pay, 30 visits per year

Maternity Pre – and Post – Natal Care

100% covered

Inpatient Rehabilitation/Skilled Nursing

14 days per year, 80% covered after deductible met

Inpatient Hospital Visits

90% covered after deductible met

Outpatient Surgical

80% covered after deductible met

Lifetime Benefit Maximum

$1 million

Annual Benefit Maximum

$100,000