** Benefit Highlights ** |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) |
• $5,750 In and Out-of-network $4,500 In-network |
Optional supplemental benefits |
• No |
Health plan deductible |
• $0 |
Other health plan deductibles? |
• In-Network: No |
Inpatient hospital coverage |
• In-Network: $195 for days 1 through 10 $0 for days 11 through 90 |
Outpatient hospital coverage |
• In-Network: $200 per visit |
Preventive care |
• In-Network: $0 copay |
• Out-of-Network: $30 |
Outpatient hospital coverage |
• Out-of-Network: $275 per visit |
Inpatient hospital coverage |
• Out-of-Network: 25% per stay |
Doctor visits |
• Primary: In-Network: $20 per visit |
• Primary: Out-of-Network: $40 per visit |
• Specialist: In-Network: $30 per visit |
• Specialist: Out-of-Network: $40 per visit |
Emergency care/Urgent care |
• Emergency: $80 per visit (always covered) |
• Urgent care: $30 per visit (always covered) |
Diagnostic procedures/lab services/imaging |
• Diagnostic tests and procedures: In-Network: $0 copay |
• Diagnostic tests and procedures: Out-of-Network: $30 |
• Lab services: In-Network: $0 copay |
• Lab services: Out-of-Network: $30 |
• Diagnostic radiology services (e.g., MRI): In-Network: $0 copay |
• Diagnostic radiology services (e.g., MRI): Out-of-Network: $30 |
• Outpatient x-rays: In-Network: $0 copay |
• Outpatient x-rays: Out-of-Network: $30 |
Wellness programs (e.g., fitness, nursing hotline) |
• Covered |
Transportation |
• Not covered |
Mental health services |
• In-Network: $175 for days 1 through 9 $0 for days 10 through 90 |
Ambulance |
• In-Network: $175 |
Skilled Nursing Facility |
• In-Network: $0 for days 1 through 20 $167.50 for days 21 through 100 |
Mental health services |
• Out-of-Network: 25% per stay |
Ambulance |
• Out-of-Network: $175 |
Skilled Nursing Facility |
• Out-of-Network: $85 for days 1 through 20 $225 for days 21 through 100 |
Mental health services |
• Outpatient group therapy visit with a psychiatrist: In-Network: $30 |
• Outpatient group therapy visit with a psychiatrist: Out-of-Network: $40 |
• Outpatient individual therapy visit with a psychiatrist: In-Network: $30 |
• Outpatient individual therapy visit with a psychiatrist: Out-of-Network: $40 |
• Outpatient group therapy visit: In-Network: $30 |
• Outpatient group therapy visit: Out-of-Network: $40 |
• Outpatient individual therapy visit: In-Network: $30 |
• Outpatient individual therapy visit: Out-of-Network: $40 |
Rehabilitation services |
• Occupational therapy visit: In-Network: $20 |
• Occupational therapy visit: Out-of-Network: $30 |
• Physical therapy and speech and language therapy visit: In-Network: $20 |
• Physical therapy and speech and language therapy visit: Out-of-Network: $30 |
Foot care (podiatry services) |
• Foot exams and treatment: In-Network: $30 |
• Foot exams and treatment: Out-of-Network: $40 |
• Routine foot care: Not covered |
Medical equipment/supplies |
• Durable medical equipment (e.g., wheelchairs, oxygen): In-Network: 20% per item |
• Durable medical equipment (e.g., wheelchairs, oxygen): Out-of-Network: 20% per item |
• Prosthetics (e.g., braces, artificial limbs): In-Network: 20% per item |
• Prosthetics (e.g., braces, artificial limbs): Out-of-Network: 20% per item |
• Diabetes supplies: In-Network: 0-20% per item |
• Diabetes supplies: Out-of-Network: 20% per item |
Medicare Part B drugs |
• Chemotherapy: In-Network: 15% |
• Chemotherapy: Out-of-Network: 25% |
• Other Part B drugs: In-Network: 15% |
• Other Part B drugs: Out-of-Network: 25% |
** Benefits Services ** |
Hearing |
• Hearing exam: In-Network: $25 |
• Hearing exam: Out-of-Network: $40 |
• Fitting/evaluation: Not covered |
• Hearing aids: In-Network: $699-999 |
Preventive dental |
• Oral exam: In-Network: $20 |
• Oral exam: Out-of-Network: $0-20 |
• Cleaning: In-Network: $0 copay |
• Cleaning: Out-of-Network: $0-20 |
• Fluoride treatment: Not covered |
• Dental x-ray(s): Not covered |
Comprehensive dental |
• Non-routine services: In-Network: $0 copay |
• Non-routine services: Out-of-Network: $25 |
• Diagnostic services: In-Network: $0 copay |
• Diagnostic services: Out-of-Network: $25 |
• Restorative services: In-Network: $0 copay |
• Restorative services: Out-of-Network: $25 |
• Endodontics: In-Network: $0 copay |
• Endodontics: Out-of-Network: $25 |
• Periodontics: In-Network: $0 copay |
• Periodontics: Out-of-Network: $25 |
• Extractions: In-Network: $0 copay |
• Extractions: Out-of-Network: $25 |
• Prosthodontics, other oral/maxillofacial surgery, other services: In-Network: $0 copay |
• Prosthodontics, other oral/maxillofacial surgery, other services: Out-of-Network: $25 |
Vision |
• Routine eye exam: Not covered |
• Other: Not covered |
• Contact lenses: Not covered |
• Eyeglasses (frames and lenses): Not covered |
• Eyeglass frames: Not covered |
• Eyeglass lenses: Not covered |
• Upgrades: Not covered |