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 |