| |
All Kids Premium
Level 1
150 – 200% |
*Children |
All Kids Premium
Level 2
200-300% |
All Kids Premium
Level 3
300-400% |
All Kids Premium
Level 4
400-500% |
All Kids Premium
Level 5
500-600% |
All Kids
Premium Level 6
600-700% |
All Kids Premium
Level 7
700-800% |
All Kids Premium
Level 8 Over 800% |
Monthly Premium |
•$15 for 1
•$25 for 2
•$30 for 3
•$35 for 4 |
|
$40 per child |
$70 per child |
$100 per child |
$150 per child |
$200 per child |
$250 per child |
$300 per child |
Max Monthly Premium |
•$40 for 5 or more persons |
$80 for 2 or
more children |
$140 for 2 or
more children |
$200 for 2 or more children |
No-Cap |
No-Cap |
No-Cap |
No-Cap |
Each Name Brand or Generic Prescription |
$5 or $3 |
$7 or $3 |
$14 or $6 |
$21 or $9 |
$28 or $12 |
$28 or $12 |
$28 or $12 |
$28 or $12 |
Each Emergency Room Visit |
$25 for non-emergency |
$30 |
$50 |
$75 |
$100 |
$100 |
$100 |
$100 |
Each Hospital Admission |
$5 per admission |
$100 per admission |
$150 per admission |
$200 per admission |
10% of HFS rate per admission |
10% of HFS rate per admission |
10% of HFS rate per admission |
25% of HFS rate per admission |
Percentage of HFS rate for each Outpatient Service |
- |
5% |
10% |
15% |
20% |
20% |
20% |
25% |
Max per Child per Year Co-Payments for Hospital Services |
- |
$500 per child |
$750 per child |
$1,000 per child |
$5,000 per child |
$5,000 per child |
$5,000 per child |
No Max |
