** Benefit Highlights ** |
Health plan deductible |
• $250 annual deductible |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) |
• $5,400 In and Out-of-network $5,400 In-network |
Optional supplemental benefits |
• Yes |
Other health plan deductibles? |
• In-Network: No |
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? |
• In-Network: No |
Inpatient hospital coverage |
• In-Network: $255 per day for days 1 through 5 $0 per day for days 6 through 90 |
Outpatient hospital coverage |
• In-Network: $0 or 20% per visit |
Preventive care |
• In-Network: $0 copay |
Inpatient hospital coverage |
• Out-of-Network: 30% per stay |
Outpatient hospital coverage |
• Out-of-Network: 40% per visit |
Preventive care |
• Out-of-Network: 40% |
Doctor visits |
• Primary: In-Network: $10 per visit |
• Primary: Out-of-Network: $25 per visit |
• Specialist: In-Network: $30 per visit |
• Specialist: Out-of-Network: $50 per visit |
Emergency care/Urgent care |
• Emergency: $90 per visit (always covered) |
• Urgent care: $25 per visit (always covered) |
Transportation |
• Not covered |
Wellness programs (e.g., fitness, nursing hotline) |
• Covered |
Skilled Nursing Facility |
• In-Network: Tier 1 $0 per day for days 1 through 20 $142 per day for days 21 through 100 Tier 2 $0 per day for days 1 through 20 $172 per day for days 21 through 100 |
Ground ambulance |
• In-Network: $295 |
Skilled Nursing Facility |
• Out-of-Network: 25% per stay |
Ground ambulance |
• Out-of-Network: $295 or 20% |
Vision |
• Routine eye exam: In-Network: $0 copay |
• Routine eye exam: Out-of-Network: $0 copay |
• Other: Not covered |
• Contact lenses: In-Network: $0 copay |
• Contact lenses: Out-of-Network: $0 copay |
• Eyeglasses (frames and lenses): In-Network: $0 copay |
• Eyeglasses (frames and lenses): Out-of-Network: $0 copay |
• Eyeglass frames: In-Network: $0 copay |
• Eyeglass frames: Out-of-Network: $0 copay |
• Eyeglass lenses: In-Network: $0 copay |
• Eyeglass lenses: Out-of-Network: $0 copay |
• Upgrades: Not covered |
Mental health services |
• Inpatient hospital - psychiatric: In-Network: $250 per day for days 1 through 5 $0 per day for days 6 through 90 |
• Inpatient hospital - psychiatric: Out-of-Network: 30% per stay |
• Outpatient group therapy visit with a psychiatrist: In-Network: $40 |
• Outpatient group therapy visit with a psychiatrist: Out-of-Network: $50 |
• Outpatient individual therapy visit with a psychiatrist: In-Network: $40 |
• Outpatient individual therapy visit with a psychiatrist: Out-of-Network: $50 |
• Outpatient group therapy visit: In-Network: $40 |
• Outpatient group therapy visit: Out-of-Network: $50 |
• Outpatient individual therapy visit: In-Network: $40 |
• Outpatient individual therapy visit: Out-of-Network: $50 |
Rehabilitation services |
• Occupational therapy visit: In-Network: $25 |
• Occupational therapy visit: Out-of-Network: $50 |
• Physical therapy and speech and language therapy visit: In-Network: $25 |
• Physical therapy and speech and language therapy visit: Out-of-Network: $50 |
Foot care (podiatry services) |
• Foot exams and treatment: In-Network: $0-30 |
• Foot exams and treatment: Out-of-Network: $50 |
• Routine foot care: In-Network: $0 copay |
• Routine foot care: Out-of-Network: $50 |
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: 40% per item |
• Prosthetics (e.g., braces, artificial limbs): In-Network: 20% per item |
• Prosthetics (e.g., braces, artificial limbs): Out-of-Network: 40% per item |
• Diabetes supplies: In-Network: $0 copay |
• Diabetes supplies: Out-of-Network: 40% per item |
Medicare Part B drugs |
• Chemotherapy: In-Network: 20% |
• Chemotherapy: Out-of-Network: 40% |
• Other Part B drugs: In-Network: 20% |
• Other Part B drugs: Out-of-Network: 40% |
** Benefits Services ** |
Diagnostic procedures/lab services/imaging |
• Diagnostic tests and procedures: In-Network: $0-150 |
• Diagnostic tests and procedures: Out-of-Network: 30% |
• Lab services: In-Network: $0-15 |
• Lab services: Out-of-Network: 30% |
• Diagnostic radiology services (e.g., MRI): In-Network: $130-150 |
• Diagnostic radiology services (e.g., MRI): Out-of-Network: 30% |
• Outpatient x-rays: In-Network: $50-110 |
• Outpatient x-rays: Out-of-Network: 30% |
Hearing |
• Hearing exam: In-Network: $30 |
• Hearing exam: Out-of-Network: 40% |
• Fitting/evaluation: In-Network: $0 copay |
• Fitting/evaluation: Out-of-Network: 20% |
• Hearing aids: In-Network: $0 copay |
• Hearing aids: Out-of-Network: 50% |
Preventive dental |
• Oral exam: In-Network: $0 copay |
• Oral exam: Out-of-Network: 20% |
• Cleaning: In-Network: $0 copay |
• Cleaning: Out-of-Network: 20% |
• Fluoride treatment: Not covered |
• Dental x-ray(s): Not covered |
Comprehensive dental |
• Non-routine services: Not covered |
• Diagnostic services: Not covered |
• Restorative services: Not covered |
• Endodontics: Not covered |
• Periodontics: Not covered |
• Extractions: Not covered |
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered |
** Optional Supplemental Benefits ** |
Package #2 |
• Comprehensive dental, Eyewear, Preventive dental |
Package #3 |
• Comprehensive dental, Eyewear, Preventive dental |
Package #1 |
• Preventive dental |
• Monthly Premium: $20.00 |
Package #2 |
• Monthly Premium: $28.00 |
Package #3 |
• Monthly Premium: $42.00 |
Package #1 |
• Deductible: N/A |
Package #2 |
• Deductible: N/A |
Package #3 |
• Deductible: N/A |