Plan Benefits Chart
Key Costs and Features | In Network | Out of Network |
---|---|---|
Annual Medical Deductible | Individual $2,500 / Family $5,000 (Combined Medical/Drug Deductible) | |
Annual Drug Deductible | Individual $2,500 / Family $5,000 (Combined Medical/Drug Deductible) | |
Maximum Out of Pocket | Individual $7,700 / Family $15,400 | |
Plan Type | PPO | |
Professional Services | In Network | Out of Network |
Preventive Care / Screening / Immunization | $0 Copay | After Medical Deductible, 50% Coinsurance |
Preconception and Prenatal Visits | $0 Copay | After Medical Deductible, 50% Coinsurance |
Family Planning (Consultation and Contraceptive Services) | $0 Copay | After Medical Deductible, 50% Coinsurance |
Primary Care Visit to Treat an Injury or Illness | $0 Copay for First 3 Visits, then Deductible Applies. After Medical Deductible is Met, $50 Copay | After Medical Deductible, 50% Coinsurance |
Specialist Visit | After Medical Deductible, $50 Copay | After Medical Deductible, 50% Coinsurance |
Acupuncture | $0 Copay for First 3 Visits, then Deductible Applies. After Medical Deductible is Met, $50 Copay | After Medical Deductible, 50% Coinsurance |
Physical Therapy | $0 Copay for First 3 Visits, then Deductible Applies. After Medical Deductible is Met, $50 Copay | After Medical Deductible, 50% Coinsurance |
Occupational Therapy | $0 Copay for First 3 Visits, then Deductible Applies. After Medical Deductible is Met, $50 Copay | After Medical Deductible, 50% Coinsurance |
Allergy Visit (Testing and Treatment) | After Medical Deductible, $50 Copay | After Medical Deductible, 50% Coinsurance |
Other Practitioner Office Visit | $0 Copay for First 3 Visits, then Deductible Applies. After Medical Deductible is Met, $50 Copay | After Medical Deductible, 50% Coinsurance |
Tests | In Network | Out of Network |
Laboratory Tests | After Medical Deductible, $10 Copay | After Medical Deductible, 50% Coinsurance |
X-Rays | After Medical Deductible, $50 Copay | After Medical Deductible, 50% Coinsurance |
Imaging (CT/PET Scans, MRIs) | After Medical Deductible $200 Copay | After Medical Deductible, 50% Coinsurance |
Outpatient Services | In Network | Out of Network |
Surgery - Facility Fee (e.g., Ambulatory Surgery Center) | After Medical Deductible, 20% Coinsurance (Chinese Hospital) / 40% Coinsurance (Other Facilities) | After Medical Deductible, 50% Coinsurance |
Outpatient Physician/Surgeon Fees | After Medical Deductible, 20% Coinsurance (Chinese Hospital) / 40% Coinsurance (Other Facilities) | After Medical Deductible, 50% Coinsurance |
Outpatient Visit | After Medical Deductible, 20% Coinsurance (Chinese Hospital) / 40% Coinsurance (Other Facilities) | After Medical Deductible, 50% Coinsurance |
Termination of Pregnancy | $0 Copay | After Medical Deductible, 50% Coinsurance |
Inpatient Services | In Network | Out of Network |
Facility Fee (e.g., Hospital Room) | After Medical Deductible, 20% Coinsurance (Chinese Hospital) / 40% Coinsurance (Other Facilities) (Up to the First 5 Days) | After Medical Deductible, 50% Coinsurance |
Inpatient Physician/Surgeon Fees | $0 Copay | After Medical Deductible, 50% Coinsurance |
Delivery and All Inpatient Services (Hospital Services) | After Medical Deductible, 20% Coinsurance (Up to the First 5 Days) | After Medical Deductible, 50% Coinsurance |
Delivery and All Inpatient Services (Professional Services) | $0 Copay | After Medical Deductible, 50% Coinsurance |
Emergency Health Coverage | In Network | Out of Network |
Emergency Room Services | After Medical Deductible, $200 Copay | After Medical Deductible, $200 Copay |
Emergency Room Physician Fee | $0 Copay | $0 Copay |
Urgent Care | After Medical Deductible, $50 Copay | After Medical Deductible, $50 Copay |
Ambulance Services | In Network | Out of Network |
Medical Transportation (Including Emergency and Non-emergency) | After Medical Deductible, 30% Coinsurance | After Medical Deductible, 30% Coinsurance |
Prescription Drug Coverage | In Network | Out of Network |
Tier 1: Generic Drugs (30-Day Supply) | After Medical Deductible, $15 Copay | Not Covered |
Tier 1: Generic Drugs (90-Day Supply) Chinese Hospital Pharmacy, or Mail Order | After Drug Deductible, $30 Copay | Not Covered |
Tier 2: Preferred Brand Drugs (30-Day Supply) | After Drug Deductible, $50 Copay | Not Covered |
Tier 2: Generic Drugs (90-Day Supply) Chinese Hospital Pharmacy, or Mail Order | After Drug Deductible, $100 Copay | Not Covered |
Tier 3: Non-Preferred Brand Drugs (30-Day Supply) | After Drug Deductible, $70 Copay | Not Covered |
Tier 3: Generic Drugs (90-Day Supply) Chinese Hospital Pharmacy, or Mail Order | After Drug Deductible, $140 Copay | Not Covered |
Tier 4: Specialty Drugs (30-Day Supply) | After Drug Deductible, 20% Coinsurance, Up to $250 Per Prescription | Not Covered |
Tier 4: Generic Drugs (90-Day Supply) Chinese Hospital Pharmacy, or Mail Order | Not Covered | Not Covered |
Medical Supplies & Equipment | In Network | Out of Network |
Medical Supplies | After Medical Deductible, 20% Coinsurance | After Medical Deductible, 50% Coinsurance |
Prosthetic Devices | After Medical Deductible, 20% Coinsurance | After Medical Deductible, 50% Coinsurance |
Durable Medical Equipment | After Medical Deductible, 20% Coinsurance | After Medical Deductible, 50% Coinsurance |
Mental Health Services | In Network | Out of Network |
Mental/Behavioral Health Outpatient Office Visits | $0 Copay | After Medical Deductible, 50% Coinsurance |
Mental/Behavioral Health Other Outpatient Items and Services | After Medical Deductible, $10 Copay | After Medical Deductible, 50% Coinsurance |
Mental/Behavioral Health Inpatient Facility Fee | After Medical Deductible, 20% Coinsurance (Up to the First 5 Days) | After Medical Deductible, 50% Coinsurance |
Mental/Behavioral Health Inpatient Professional Fee | $0 Copay | After Medical Deductible, 50% Coinsurance |
Chemical Dependency Services | In Network | Out of Network |
Substance Use Disorder Outpatient Office Visits | $0 Copay | After Medical Deductible, 50% Coinsurance |
Substance Use Disorder Other Outpatient items and Services | After Medical Deductible, $10 Copay | After Medical Deductible, 50% Coinsurance |
Substance Use Disorder Inpatient Facility Services | After Medical Deductible, 20% Coinsurance (Up to the First 5 Days) | After Medical Deductible, 50% Coinsurance |
Substance Use Disorder Inpatient Professional Fee | $0 Copay | After Medical Deductible, 50% Coinsurance |
Home Health Services | In Network | Out of Network |
Home Health Care | After Medical Deductible, $45 Copay | After Medical Deductible, 50% Coinsurance |
Infusion Services | After Medical Deductible, $45 Copay | After Medical Deductible, 50% Coinsurance |
Rehabilitation Services | After Medical Deductible, $45 Copay | After Medical Deductible, 50% Coinsurance |
Habilitation Services | After Medical Deductible, $45 Copay | After Medical Deductible, 50% Coinsurance |
Skilled Nursing Care | After Medical Deductible, 40% Coinsurance | After Medical Deductible, 50% Coinsurance |
Hospice Services | After Medical Deductible, $0 Copay | After Medical Deductible, 50% Coinsurance |
Pre-Hospice Consultation | After Medical Deductible, $0 Copay | After Medical Deductible, 50% Coinsurance |
Inpatient Respite Care | After Medical Deductible, $0 Copay | After Medical Deductible, 50% Coinsurance |
Infertility | In Network | Out of Network |
Infertility Imaging Tests | Not Covered | Not Covered |
Infertility Drugs | Not Covered | Not Covered |
Infertility Laboratory Tests | Not Covered | Not Covered |
Infertility Specialist Office Visit | Not Covered | Not Covered |
Artificial Insemination (AI) | Not Covered | Not Covered |
Gamete intrafallopian transfer (GIFT) | Not Covered | Not Covered |