The Plan Offers:
Deductible / Co-Insurance 
Maximum out of pocket (including deductibles)
Office Visits – Primary Care Physician
Office Visits – Specialist
Wellness Visit
Diagnostics-X-Ray & Lab
Diagnostics-Complex Imaging
Outpatient Services/Surgery
Rehab Services (physical, occupational, and speech therapy)
Hospitalization
Emergency Room
SMH Walk-In Medical Center
Maternity pre-natal & monitoring
Maternity hospitalization
Behavioral Health Services
Prescription – (subject to maximum)
Durable Medical Equipment
Lifetime Maximum Benefit
To see the list of Providers in the
Charter Health Plan Network click here
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Amount:
$500/80-20% to $10,000
$2,500 individual $7,500 family
$20 copay (4 per calendar year)
Deductible & Co-Insurance
100% up to $300 maximum
Deductible & Co-Insurance
Deductible & Co-Insurance
Deductible & Co-Insurance
20% after deductible has been met
Deductible & Co-Insurance
$100 per visit plus Deductible & Co-Insurance
$75 per visit plus Deductible & Co-Insurance
$35 Copay
Deductible & Co-Insurance
$0 Copay first 4 visits, $30 Copay for visits 5-20
$15 Generic/$40 Brand
20% after deductible has been met
$2,000,000 |
