|In Network||Out of Network|
Deductible must be met before Coinsurance applies.
|$1,000, $2,000, $2,500, $3,500, $5,000, $7,500, $10,000||$2,000, $4,000, $5,000, $7,000, $10,000, $15,000, $20,000|
|Coinsurance Out-of-Pocket Maximum||$4,500||$9,000|
|Preventive Care Services||$0||50%|
|Medical Office Visits|
|Inpatient & Outpatient||30%||50%|
|$1,500 Maximum per service, per year||30%||50%|
|Lifetime Maximum Benefit||Unlimited|
|Prescription Drug Benefits||Must use participating pharmacy|
|Brand Name Preferred||$35|
|Brand Name Non-Preferred||$55|
This summary contains highlights only and is subject to change. The specific terms of coverage are listed in the Evidence of Coverage Handbook, including details on Limitations and Exclusions. Additionally, some services require Prior Authorization.
Standardized Summary of Benefit and Coverage Document (SBC) - The Standardized Summary of Benefits and Coverage is available for you per the U.S. Department of Health and Human Services and the Patient Protection and Affordable Care Act (PPACA). It describes the plan's benefits and coverage.
Glossary - The Uniform Glossary is available to you per the U.S. Department of Health and Human Services and the Patient Protection and Affordable Care Act (PPACA). It's a glossary that defines health coverage and medical terminology used in the SBC.
If you would like a copy of the SBC, you can request it by calling the SBC Hotline at (505) 727-1707 or by emailing SBC@lovelace.com. When making a request, please include your name, member number, date of birth, and the address and/or email address where you would like to receive your copy of the SBC.