** Benefit Highlights ** |
Health plan deductible |
• $0 |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) |
• $3,400 In and Out-of-network $3,400 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: $75 per day for days 1 through 5 $0 per day for days 6 through 90 |
Outpatient hospital coverage |
• In-Network: $0 copay |
Preventive care |
• In-Network: $0 copay |
Inpatient hospital coverage |
• Out-of-Network: $75 per day for days 1 through 5 $0 per day for days 6 and beyond |
Outpatient hospital coverage |
• Out-of-Network: $0 copay |
Preventive care |
• Out-of-Network: $0 copay |
Doctor visits |
• Primary: In-Network: $10 per visit |
• Primary: Out-of-Network: $10 per visit |
• Specialist: In-Network: $20 per visit |
• Specialist: Out-of-Network: $20 per visit |
Emergency care/Urgent care |
• Emergency: $120 per visit (always covered) |
• Urgent care: $0 copay |
Transportation |
• Not covered |
Wellness programs (e.g., fitness, nursing hotline) |
• Covered |
Skilled Nursing Facility |
• In-Network: $0 copay |
Ground ambulance |
• In-Network: $0 copay |
Skilled Nursing Facility |
• Out-of-Network: $0 copay |
Ground ambulance |
• Out-of-Network: $0 copay |
Vision |
• Routine eye exam: In-Network: $10 |
• Routine eye exam: Out-of-Network: 100% |
• Other: Not covered |
• Contact lenses: Not covered |
• Eyeglasses (frames and lenses): Not covered |
• Eyeglass frames: Not covered |
• Eyeglass lenses: Not covered |
• Upgrades: Not covered |
Mental health services |
• Inpatient hospital - psychiatric: In-Network: $0 copay |
• Inpatient hospital - psychiatric: Out-of-Network: $0 copay per stay |
• Outpatient group therapy visit with a psychiatrist: In-Network: $0 copay |
• Outpatient group therapy visit with a psychiatrist: Out-of-Network: $0 copay |
• Outpatient individual therapy visit with a psychiatrist: In-Network: $0 copay |
• Outpatient individual therapy visit with a psychiatrist: Out-of-Network: $0 copay |
• Outpatient group therapy visit: In-Network: $0 copay |
• Outpatient group therapy visit: Out-of-Network: $0 copay |
• Outpatient individual therapy visit: In-Network: $0 copay |
• Outpatient individual therapy visit: Out-of-Network: $0 copay |
Rehabilitation services |
• Occupational therapy visit: In-Network: $20 |
• Occupational therapy visit: Out-of-Network: $20 |
• Physical therapy and speech and language therapy visit: In-Network: $20 |
• Physical therapy and speech and language therapy visit: Out-of-Network: $20 |
Foot care (podiatry services) |
• Foot exams and treatment: In-Network: $20 |
• Foot exams and treatment: Out-of-Network: $20 |
• Routine foot care: Not covered |
Medical equipment/supplies |
• Durable medical equipment (e.g., wheelchairs, oxygen): In-Network: $0 copay |
• Durable medical equipment (e.g., wheelchairs, oxygen): Out-of-Network: $0 copay |
• Prosthetics (e.g., braces, artificial limbs): In-Network: $0 copay |
• Prosthetics (e.g., braces, artificial limbs): Out-of-Network: $0 copay |
• Diabetes supplies: In-Network: $0 copay |
• Diabetes supplies: Out-of-Network: $0 copay |
Medicare Part B drugs |
• Chemotherapy: In-Network: 20% |
• Chemotherapy: Out-of-Network: 20% |
• Other Part B drugs: In-Network: 20% |
• Other Part B drugs: Out-of-Network: 20% |
** Benefits Services ** |
Diagnostic procedures/lab services/imaging |
• Diagnostic tests and procedures: In-Network: $0 copay |
• Diagnostic tests and procedures: Out-of-Network: $0 copay |
• Lab services: In-Network: $0 copay |
• Lab services: Out-of-Network: $0 copay |
• Diagnostic radiology services (e.g., MRI): In-Network: $0 copay |
• Diagnostic radiology services (e.g., MRI): Out-of-Network: $0 copay |
• Outpatient x-rays: In-Network: $0 copay |
• Outpatient x-rays: Out-of-Network: $0 copay |
Hearing |
• Hearing exam: In-Network: $0 copay |
• Hearing exam: Out-of-Network: $0 copay |
• Fitting/evaluation: Not covered |
• Hearing aids: In-Network: $1,220-1,985 |
• Hearing aids: Out-of-Network: $1,220-1,985 |
Preventive dental |
• Office visit: In-Network: $30.00 |
• Office visit: Out-of-Network: 100% |
• Oral exam: Covered under office visit |
• Cleaning: Covered under office visit |
• 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 #1 |
• Comprehensive dental, Preventive dental |
• Monthly Premium: $35.00 |
• Deductible: $100.00 |