US Health and Life

Gold

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $3,500.00 Family: $7,000 Per Person: $3,500
Combined Medical and Drug Out of Pocket Maximum	Individual: $6,000.00 Family: $12,000 Per Person: $6,000

Office Visit

Primary Doctor	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Generic Drugs	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Exclusions: Blood
Inpatient Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Also covers surrogate mother if there is a petition to adopt within 90 days of birth.
Pre and Postnatal Office Visit	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Also covers surrogate mother if there is a petition to adopt within 90 days of birth.

Vision

Routine Eye Exams For Children

CoPay: No Charge after deductible
CoInsurance: No Charge after deductible
Covered: Covered

Major Dental Care

Routine Dental Checkups for Children	CoPay: Not Applicable CoInsurance: Not Applicable Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered

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