Child-Only Plans

BENEFITS
	PPO 30%
	In Network	Out of Network
Annual Deductible 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
Non-Specialist	$25	50%
Specialist	$50	50%
Emergency Care	$200
Urgent Care	$50
Hospital Services
Inpatient & Outpatient	30%	50%
Acupuncture/Chiropractic
$1,500 Maximum per service, per year	30%	50%
Lifetime Maximum Benefit	Unlimited
Prescription Drug Benefits	Must use participating pharmacy
Generic	$10
Brand Name Preferred	$35
Brand Name Non-Preferred	$55
Specialty Medications	20%

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.