Plan Benefits Chart
| Key Costs and Features | |
|---|---|
| Annual Medical Deductible | Individual $2,500 / Family $5,000 |
| Annual Drug Deductible | Individual $300 / Family $600 |
| Maximum Out of Pocket | Individual $8,750 / Family $17,500 |
| 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 | $55 Copay |
| Specialist Visit | $90 Copay |
| Acupuncture | $55 Copay |
| Physical Therapy | $55 Copay |
| Occupational Therapy | $55 Copay |
| Allergy Visit (Testing and Treatment) | $90 Copay |
| Other Practitioner Office Visit | $55 Copay |
| Tests | |
| Laboratory Tests | $55 Copay |
| X-Rays | $90 Copay |
| Imaging (CT/PET Scans, MRIs) | $300 Copay |
| Outpatient Services | |
| Surgery - Facility Fee (e.g., Ambulatory Surgery Center) | After Medical Deductible, 35% Coinsurance |
| Outpatient Physician/Surgeon Fees | 30% Coinsurance |
| Outpatient Visit | 30% Coinsurance |
| Termination of Pregnancy | After Medical Deductible, 35% Coinsurance |
| Inpatient Services | |
| Facility Fee (e.g., Hospital Room) | After Medical Deductible, 40% Coinsurance |
| Inpatient Physician/Surgeon Fees | 40% Coinsurance |
| Delivery and All Inpatient Services (Hospital Services) | After Medical Deductible, 40% Coinsurance |
| Delivery and All Inpatient Services (Professional Services) | 40% Coinsurance |
| Emergency Health Coverage | |
| Emergency Room Services | After Medical Deductible, 30% Coinsurance |
| Emergency Room Physician Fee | $0 Copay |
| Urgent Care | $55 Copay |
| Ambulance Services | |
| Medical Transportation (Including Emergency and Non-emergency) | After Medical Deductible, 30% Coinsurance |
| Prescription Drug Coverage | |
| Tier 1: Generic Drugs (30-Day Supply) | $19 Copay |
| Tier 1: Generic Drugs (90-Day Supply) Chinese Hospital Pharmacy, or Mail Order | $38 Copay |
| Tier 2: Preferred Brand Drugs (30-Day Supply) | After Drug Deductible, $85 Copay |
| Tier 2: Generic Drugs (90-Day Supply) Chinese Hospital Pharmacy, or Mail Order | After Drug Deductible, $170 Copay |
| Tier 3: Non-Preferred Brand Drugs (30-Day Supply) | After Drug Deductible, $110 Copay |
| Tier 3: Generic Drugs (90-Day Supply) Chinese Hospital Pharmacy, or Mail Order | After Drug Deductible, $220 Copay |
| Tier 4: Specialty Drugs (30-Day Supply) | After Drug Deductible, 30% 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 | 40% Coinsurance |
| Prosthetic Devices | 40% Coinsurance |
| Durable Medical Equipment | 40% Coinsurance |
| Mental Health Services | |
| Mental/Behavioral Health Outpatient Office Visits | $0 Copay |
| Mental/Behavioral Health Other Outpatient Items and Services | $55 Copay |
| Mental/Behavioral Health Inpatient Facility Fee | After Medical Deductible, 40% Coinsurance |
| Mental/Behavioral Health Inpatient Professional Fee | 40% Coinsurance |
| Chemical Dependency Services | |
| Substance Use Disorder Outpatient Office Visits | $0 Copay |
| Substance Use Disorder Other Outpatient items and Services | $55 Copay |
| Substance Use Disorder Inpatient Facility Services | After Medical Deductible, 40% Coinsurance |
| Substance Use Disorder Inpatient Professional Fee | 40% Coinsurance |
| Home Health Services | |
| Home Health Care | $45 Copay |
| Infusion Services | $45 Copay |
| Rehabilitation Services | $55 Copay |
| Habilitation Services | $55 Copay |
| Skilled Nursing Care | After Medical Deductible, 40% Coinsurance |
| 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 |