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 BACK
Comprehesive + Frontera
Great combination of the Comprehesive plan option and the Frontera plan option. No limits on stateside doctor visits. Non-emergency in-patient and out-patient
surgeries are covered stateside. Stateside prescription drug coverage
identical to the Comprehensive plan option.
Get Forms
2007 Preferred Drug List
- English
- Spanish
BENEFITS |
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Lifetime Maximum Coverage Amount |
$5,000,000 |
Co-Insurance Limit
(individual/family)
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$1,000 / $3,000
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$5,000 / $15,000 |
None |
Calendar Year Deductible (individual/family) |
$300 / $900
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$500 / $1,500 |
None |
Max Out of Pocket
(individual/family) |
$1,300 / $3,900
(excludes copays & benefit exclusions)
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$5,500 / $16,500 (excludes copays & benefit exclusions) |
Copays + $ over Benefit Limits |
Doctor's Office Visit |
Primary Care Physician |
$15 copay |
50% after deductible |
$5 copay |
Specialty Care Physician |
$30 copay |
50% after deductible |
$5 copay |
X-Ray
(in free standing facility) |
$15 copay |
50% after deductible |
100%
($1000 max/calendar year) |
Lab Fees
(in free standing facility) |
$15 copay |
50% after deductible |
100%
($750 max/calendar Year) |
Inpatient Physical Therapy & Rehab |
$30 copay |
50% after deductible |
$5 copay
($1000 max/calendar year) |
Emergency Care |
Emergency Room Visits
(copay waived if admitted)
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50% after deductible |
$10 copay |
Hospital |
Room and Board |
80% after deductible |
50% after deductible |
100% |
In Hospital Xray & Lab |
80% after deductible |
50% after deductible |
100% |
Hospital Extras |
80% after deductible |
50% after deductible |
100% |
Intensive Care |
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100% |
Cardiovascular Disorder |
80% after deductible |
50% after deductible |
100% |
Immune System Disorder |
80% after deductible |
50% after deductible |
100% |
Hearing & Eye Exam
1 per calendar year |
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$5 copay |
Durable Medical Equipment Coverage: |
80% after deductible
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50% after deductible |
100%
($500 max/calendar year) |
Prescription Drugs: |
Important: Rx written in Mexico must be filled in Mexico. Rx written stateside must be filled stateside. |
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None |
None |
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$5 copay |
$5 copay |
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$20 copay |
Not Covered |
Non-Preferred |
$35 copay |
Not Covered |
last updated: 2.8.10 jll
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