Plan Benefits Chart
Key Costs and Features | |
---|---|
Annual Medical Deductible | $0 |
Annual Drug Deductible | $0 |
Maximum Out of Pocket | Individual $4,500 / Family $9,000 |
Plan Type | HMO |
Professional Services | |
Preventive Care / Screening / Immunization | $0 Copay |
Preconception and Prenatal Visits | $0 Copay |
Family Planning (Consultation and Contraceptive Services) | $0 Copay |
Primary Care Visit to Treat an Injury or Illness | $20 Copay |
Specialist Visit | $30 Copay |
Acupuncture | $20 Copay |
Physical Therapy | $20 Copay |
Occupational Therapy | $20 Copay |
Allergy Visit (Testing and Treatment) | $30 Copay |
Other Practitioner Office Visit | $20 Copay |
Tests | |
Laboratory Tests | $20 Copay |
X-Rays | $30 Copay |
Imaging (CT/PET Scans, MRIs) | $100 Copay |
Outpatient Services | |
Surgery - Facility Fee (e.g., Ambulatory Surgery Center) | $100 Copay |
Outpatient Physician/Surgeon Fees | $25 Copay |
Outpatient Visit | 10% Coinsurance |
Termination of Pregnancy | $100 Copay |
Inpatient Services | |
Facility Fee (e.g., Hospital Room) | $250 Per Day (Up to the First 5 Days) |
Inpatient Physician/Surgeon Fees | $0 Copay |
Delivery and All Inpatient Services (Hospital Services) | $250 Per Day (Up to the First 5 Days) |
Delivery and All Inpatient Services (Professional Services) | $0 Copay |
Emergency Health Coverage | |
Emergency Room Services | $150 Copay |
Emergency Room Physician Fee | $0 Copay |
Urgent Care | $20 Copay |
Ambulance Services | |
Medical Transportation (Including Emergency and Non-emergency) | $150 Copay |
Prescription Drug Coverage | |
Tier 1: Generic Drugs (30-Day Supply) | $5 Copay |
Tier 1: Generic Drugs (90-Day Supply) Chinese Hospital Pharmacy, or Mail Order | $10 Copay |
Tier 2: Preferred Brand Drugs (30-Day Supply) | $20 Copay |
Tier 2: Generic Drugs (90-Day Supply) Chinese Hospital Pharmacy, or Mail Order | $40 Copay |
Tier 3: Non-Preferred Brand Drugs (30-Day Supply) | $30 Copay |
Tier 3: Generic Drugs (90-Day Supply) Chinese Hospital Pharmacy, or Mail Order | $60 Copay |
Tier 4: Specialty Drugs (30-Day Supply) | 10% Coinsurance, Up to $250 Per Prescription |
Tier 4: Generic Drugs (90-Day Supply) Chinese Hospital Pharmacy, or Mail Order | Not Covered |
Medical Supplies & Equipment | |
Medical Supplies | 10% Coinsurance |
Prosthetic Devices | 10% Coinsurance |
Durable Medical Equipment | 10% Coinsurance |
Mental Health Services | |
Mental/Behavioral Health Outpatient Office Visits | $20 Copay |
Mental/Behavioral Health Other Outpatient Items and Services | $20 Copay |
Mental/Behavioral Health Inpatient Facility Fee | $250 Per Day (Up to the First 5 Days) |
Mental/Behavioral Health Inpatient Professional Fee | $0 Copay |
Chemical Dependency Services | |
Substance Use Disorder Outpatient Office Visits | $20 Copay |
Substance Use Disorder Other Outpatient items and Services | $20 Copay |
Substance Use Disorder Inpatient Facility Services | $250 Copay Per Day (Up to the First 5 Days) |
Substance Use Disorder Inpatient Professional Fee | $0 Copay |
Home Health Services | |
Home Health Care | $20 Copay |
Infusion Services | $20 Copay |
Rehabilitation Services | $20 Copay |
Habilitation Services | $20 Copay |
Skilled Nursing Care | $150 Per Day (Up to the First 5 Days) |
Hospice Services | $0 Copay |
Pre-Hospice Consultation | $0 Copay |
Inpatient Respite Care | $0 Copay |
Infertility - Check with your administrator about available rider | |
Infertility Imaging Tests | Not Covered |
Infertility Drugs | Not Covered |
Infertility Laboratory Tests | Not Covered |
Infertility Specialist Office Visit | Not Covered |
Artificial Insemination (AI) | Not Covered |
Gamete intrafallopian transfer (GIFT) | Not Covered |