Cuadro de beneficios del plan
| Costos y características clave | En red | Fuera de la red |
|---|---|---|
| Deducible médico anual | Individual $2,500 / Family $5,000 (Combined Medical/Drug Deductible) | |
| Deducible anual de medicamentos | Individual $2,500 / Family $5,000 (Combined Medical/Drug Deductible) | |
| Máximos de por Vida | Individual $7,700 / Family $15,400 | |
| Tipo de plan | PPO | |
| Servicios profesionales | En red | Fuera de la red |
| Cuidado Preventivo / Detección / Vacunación | $0 Copay | After Medical Deductible, 50% Coinsurance |
| Consultas Preconcepcionales y Prenatales | $0 Copay | After Medical Deductible, 50% Coinsurance |
| Planificación Familiar (Servicios de consulta y anticoncepción) | $0 Copay | After Medical Deductible, 50% Coinsurance |
| Consulta de atención primaria para tratar una lesión o enfermedad | $0 Copay for First 3 Visits, then Deductible Applies. After Medical Deductible is Met, $50 Copay | After Medical Deductible, 50% Coinsurance |
| Consulta con el especialista | After Medical Deductible, $50 Copay | After Medical Deductible, 50% Coinsurance |
| Acupuntura | $0 Copay for First 3 Visits, then Deductible Applies. After Medical Deductible is Met, $50 Copay | After Medical Deductible, 50% Coinsurance |
| Terapia física | $0 Copay for First 3 Visits, then Deductible Applies. After Medical Deductible is Met, $50 Copay | After Medical Deductible, 50% Coinsurance |
| Terapia ocupacional | $0 Copay for First 3 Visits, then Deductible Applies. After Medical Deductible is Met, $50 Copay | After Medical Deductible, 50% Coinsurance |
| Consulta de alergia (prueba y tratamiento) | After Medical Deductible, $50 Copay | After Medical Deductible, 50% Coinsurance |
| Consulta en la oficina de otro practicante | $0 Copay for First 3 Visits, then Deductible Applies. After Medical Deductible is Met, $50 Copay | After Medical Deductible, 50% Coinsurance |
| Pruebas | En red | Fuera de la red |
| Pruebas de laboratorio | After Medical Deductible, $10 Copay | After Medical Deductible, 50% Coinsurance |
| Rayos X | After Medical Deductible, $50 Copay | After Medical Deductible, 50% Coinsurance |
| Imágenes (tomografías computarizadas/PET, resonancias magnéticas) | After Medical Deductible $200 Copay | After Medical Deductible, 50% Coinsurance |
| Servicios para pacientes ambulatorios | En red | Fuera de la red |
| Cirugía: tarifa del centro (p. ej., centro de cirugía ambulatoria) | After Medical Deductible, 20% Coinsurance (Chinese Hospital) / 40% Coinsurance (Other Facilities) | After Medical Deductible, 50% Coinsurance |
| Honorarios del médico / cirujano ambulatorio | After Medical Deductible, 20% Coinsurance (Chinese Hospital) / 40% Coinsurance (Other Facilities) | After Medical Deductible, 50% Coinsurance |
| Consulta ambulatoria | After Medical Deductible, 20% Coinsurance (Chinese Hospital) / 40% Coinsurance (Other Facilities) | After Medical Deductible, 50% Coinsurance |
| Interrupción del embarazo | After Medical Deductible, 20% Coinsurance (Chinese Hospital) / 40% Coinsurance (Other Facilities) | After Medical Deductible, 50% Coinsurance |
| Servicios para pacientes hospitalizados | En red | Fuera de la red |
| Tarifa de instalación (p. ej., habitación de hospital) | After Medical Deductible, 20% Coinsurance (Chinese Hospital) / 40% Coinsurance (Other Facilities) (Up to the First 5 Days) | After Medical Deductible, 50% Coinsurance |
| Honorarios del médico/cirujano para pacientes internados | $0 Copay | After Medical Deductible, 50% Coinsurance |
| Parto y todos los servicios para pacientes hospitalizados (servicios hospitalarios) | After Medical Deductible, 20% Coinsurance (Up to the First 5 Days) | After Medical Deductible, 50% Coinsurance |
| Parto y todos los servicios para pacientes hospitalizados (servicios profesionales) | $0 Copay | After Medical Deductible, 50% Coinsurance |
| Cobertura de salud de emergencia | En red | Fuera de la red |
| Servicios de sala de emergencia | After Medical Deductible, $200 Copay | After Medical Deductible, $200 Copay |
| Tarifa del médico de la sala de emergencias | $0 Copay | $0 Copay |
| Atención de urgencias | After Medical Deductible, $50 Copay | After Medical Deductible, $50 Copay |
| Servicios de Ambulancia | En red | Fuera de la red |
| Transporte médico (incluidos los de emergencia y los que no son de emergencia) | After Medical Deductible, 30% Coinsurance | After Medical Deductible, 30% Coinsurance |
| Cobertura de medicamentos recetados | En red | Fuera de la red |
| Nivel 1: Medicamentos genéricos (suministro para 30 días) | After Medical Deductible, $15 Copay | Not Covered |
| Nivel 1: Medicamentos genéricos (suministro para 90 días) farmacia de Chinese Hospital o pedido por correo | After Drug Deductible, $30 Copay | Not Covered |
| Nivel 2: Medicamentos de marca preferidos (suministro para 30 días) | After Drug Deductible, $50 Copay | Not Covered |
| Nivel 2: Medicamentos genéricos (suministro para 90 días) farmacia de Chinese Hospital o pedido por correo | After Drug Deductible, $100 Copay | Not Covered |
| Nivel 3: Medicamentos de marca no preferidos (suministro para 30 días) | After Medical Deductible, $70 Copay | Not Covered |
| Nivel 3: Medicamentos genéricos (suministro para 90 días) farmacia de Chinese Hospital o pedido por correo | After Medical Deductible, $140 Copay | Not Covered |
| Nivel 4: Medicamentos especiales (suministro para 30 días) | After Medical Deductible, 20% Coinsurance, Up to $250 Per Prescription | Not Covered |
| Nivel 4: Medicamentos genéricos (suministro para 90 días) farmacia de Chinese Hospital o pedido por correo | Not Covered | Not Covered |
| Suministros y equipos médicos | En red | Fuera de la red |
| Suministros médicos | After Medical Deductible, 20% Coinsurance | After Medical Deductible, 50% Coinsurance |
| Dispositivos protésicos | After Medical Deductible, 20% Coinsurance | After Medical Deductible, 50% Coinsurance |
| Equipo médico duradero | After Medical Deductible, 20% Coinsurance | After Medical Deductible, 50% Coinsurance |
| Servicios de salud mental | En red | Fuera de la red |
| Consultas para pacientes ambulatorios de salud mental/conductual | $0 Copay | After Medical Deductible, 50% Coinsurance |
| Otros artículos y servicios para pacientes ambulatorios, salud mental/del comportamiento | After Medical Deductible, $10 Copay | After Medical Deductible, 50% Coinsurance |
| Tarifa del centro para pacientes hospitalizados por salud mental/conductual | After Medical Deductible, 20% Coinsurance (Up to the First 5 Days) | After Medical Deductible, 50% Coinsurance |
| Tarifa profesional para pacientes hospitalizados por salud mental/conductual | $0 Copay | After Medical Deductible, 50% Coinsurance |
| Servicios de dependencia química | En red | Fuera de la red |
| Visitas al consultorio para pacientes ambulatorios por uso de sustancias | $0 Copay | After Medical Deductible, 50% Coinsurance |
| Otros artículos y servicios para pacientes ambulatorios, trastorno por uso de sustancias | After Medical Deductible, $10 Copay | After Medical Deductible, 50% Coinsurance |
| Servicios de instalaciones para pacientes internados debido a trastornos por uso de sustancias | After Medical Deductible, 20% Coinsurance (Up to the First 5 Days) | After Medical Deductible, 50% Coinsurance |
| Tarifa profesional para pacientes internados por trastorno por uso de sustancias | $0 Copay | After Medical Deductible, 50% Coinsurance |
| Servicios de salud en el hogar | En red | Fuera de la red |
| Cuidado de la salud en el hogar | After Medical Deductible, $45 Copay | After Medical Deductible, 50% Coinsurance |
| Servicios de infusión | After Medical Deductible, $45 Copay | After Medical Deductible, 50% Coinsurance |
| Servicios de rehabilitación | After Medical Deductible, $45 Copay | After Medical Deductible, 50% Coinsurance |
| Servicios de habilitación | After Medical Deductible, $45 Copay | After Medical Deductible, 50% Coinsurance |
| Cuidado de enfermería especializada | After Medical Deductible, 40% Coinsurance | After Medical Deductible, 50% Coinsurance |
| Servicios de hospicio | After Medical Deductible, $0 Copay | After Medical Deductible, 50% Coinsurance |
| Consulta previa a ingresar al hospicio | After Medical Deductible, $0 Copay | After Medical Deductible, 50% Coinsurance |
| Cuidado de relevo para pacientes hospitalizados | After Medical Deductible, $0 Copay | After Medical Deductible, 50% Coinsurance |
| Esterilidad | En red | Fuera de la red |
| Pruebas de imágenes de infertilidad | Not Covered | Not Covered |
| Medicamentos para la infertilidad | Not Covered | Not Covered |
| Pruebas de laboratorio de infertilidad | Not Covered | Not Covered |
| Visita al consultorio del especialista en infertilidad | Not Covered | Not Covered |
| Inseminación Artificial (IA) | Not Covered | Not Covered |
| Transferencia intrafalopiana de gametos (GIFT) | Not Covered | Not Covered |