Friday Health Plan

FRIDAY Bronze Plus Copay: $0 Well Visit, up to $30 Preferred Generic Rx, $0 Vision Exam

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $8,700 Family: $17,400 Per Person: $8,700
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700 Family: $17,400 Per Person: $8,700

Office Visit

Primary Doctor	CoPay: No Charge CoInsurance: No Charge Covered: Covered
Specialist	CoPay: $150.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $160.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Value displayed reflects the maximum copay/coinsurance amount a member will pay.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Value displayed reflects the maximum copay/coinsurance amount a member will pay.
Generic Drugs	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Value displayed reflects the maximum copay/coinsurance amount a member will pay.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Value displayed reflects the maximum copay/coinsurance amount a member will pay.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $175.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: $150.00 CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: No Charge
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: 1 Exam & 1 Refraction Exam per Year

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Basic Dental Care - Child	Covered: Not Covered
Major Dental Care - Child	Covered: Not Covered

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