Name: North West Health Services
Address: United States

	In-Network	Non-Network
Deductible (Individual/Family)	$3,400/$6,800	$3,400/$6,800
Member Coinsurance	0%	20%
Out-of-Pocket Max (Individual/Family) (Includes deductible, co-insurance, per visit and RX copays)	$3,400/$6,800	$6,800/$13,600
Physician Office Visit
Primary Care	Deductible then 0%	Deductible then 20%
Specialist	Deductible then 0%	Deductible then 20%
Hospital Services Inpatient & Outpatient	Deductible then 0%	Deductible then 20%
Diagnostic Lab & X-Ray	Deductible then 0%	Deductible then 20%
Urgent Care (Includes lab only)	Deductible then 0%	Deductible then 20%
Emergency Room	Deductible then 0%	Deductible then 0%
Preventive Services (Includes Well Woman Exam, Prostate Exam, Skin Cancer Screening, Routine Physical Exam, and Well Baby Care)	Covered at 100% (Deductible Waived)	Deductible then 20%

Prescription Drugs 30-day Retail 90-day Mail order twice the retail copay	In-Network	Non-Network
Generic	Deductible then 0%	Deductible then 50%
Brand - Preferred	Deductible then 0%	Deductible then 50%
Brand - Non-Preferred	Deductible then 0%	Deductible then 50%

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	In-Network	Non-Network
Deductible (Individual/Family)	$2,800/$5,600	$2,800/$5,600
Member Coinsurance	0%	20%
Out-of-Pocket Max (Individual/Family) (Includes deductible, co-insurance, per visit and RX copays)	$2,800/$5,600	$5,600/$11,200
Physician Office Visit
Primary Care	$10 Copay, then 0%	$10 Copay, then 20%
Specialist	$30 Copay, then 0%	$30 Copay, then 20%
Hospital Services Inpatient & Outpatient	Deductible then 0%	Deductible then 20%
Diagnostic Lab & X-Ray	Deductible then 0%	Deductible then 20%
Urgent Care (Includes lab only)	Deductible then 0%	Deductible then 20%
Emergency Room	Deductible then 0%	Deductible then 0%
Preventive Services (Includes Well Woman Exam, Prostate Exam, Skin Cancer Screening, Routine Physical Exam, and Well Baby Care)	Covered at 100% (Deductible Waived)	Deductible then 20%

Prescription Drugs 30-day Retail 90-day Mail order twice the retail copay	In-Network	Non-Network
Generic	$15 Copay	Deductible then 50% + $15 Copay
Brand - Preferred	$35 Copay	Deductible then 50% + $30 Copay
Brand - Non-Preferred	$70 Copay	Deductible then 50% + $70 Copay

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	In-Network	Non-Network
Deductible (Individual/Family)	$1,000/$2,000	$1,000/$2,000
Member Coinsurance	20%	40%
Out-of-Pocket Max (Individual/Family) (Includes deductible, co-insurance, per visit and RX copays)	$3,000/$6,000	$6,000/$12,000
Physician Office Visit
Primary Care	$10 Copay, then 20%	Deductible then 40%
Specialist	$30 Copay, then 20%	Deductible then 40%
Hospital Services Inpatient & Outpatient	Deductible then 20%	Deductible then 40%
Diagnostic Lab & X-Ray	Deductible then 20%	Deductible then 40%
Urgent Care (Includes lab only)	$30 Copay, then 20%	Deductible then 40%
Emergency Room	$150 Copay	$150 Copay
Preventive Services (Includes Well Woman Exam, Prostate Exam, Skin Cancer Screening, Routine Physical Exam, and Well Baby Care)	Covered at 100% (Deductible & Copay Waived)	Deductible then 40%

Prescription Drugs 30-day Retail 90-day Mail order twice the retail copay	In-Network	Non-Network
Generic	$10 Copay	Deductible then 50% +$10 Copay
Brand - Preferred	$30 Copay	Deductible then 50% +$30 Copay
Brand - Non-Preferred	$50 Copay	Deductible then 50% +$50 Copay

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Medical Benefits