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 Benefit Explanation: Pages 7, 15
Specialist	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Pages 7-8

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Pages 12-13, 20-21
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Pages 12-13, 20-21
Generic Drugs	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Pages 12-13, 20-21
Specialty Drugs	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Exclusions: Subject to Prior Authorization Benefit Explanation: Pages 12-13, 20-21

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Page 22
Inpatient Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Page 22

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Pages 10-11, 23
Urgent Care Facility	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Pages 10, 23

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Page 28
Pre and Postnatal Office Visit	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Page 28

Vision

Routine Eye Exams For Children

CoPay: $25.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: Pages 14, 31; FEDVIP BlueVision, Page 14

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered Benefit Explanation: MIChild, Pages 8-9
Routine Dental Checkups for Adults	Covered: Not Covered

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