Plan Benefits Chart
| Key Costs and Features | |
|---|---|
| Annual Medical Deductible | $0 |
| Annual Drug Deductible | $0 |
| Maximum Out of Pocket | Individual $3,000 / Family $6,000 |
| 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 | $40 Copay |
| Specialist Visit | $40 Copay |
| Acupuncture | $40 Copay |
| Physical Therapy | $40 Copay |
| Occupational Therapy | $40 Copay |
| Allergy Visit (Testing and Treatment) | $40 Copay |
| Other Practitioner Office Visit | $40 Copay |
| Tests | |
| Laboratory Tests | $10 Copay |
| X-Rays | $10 Copay |
| Imaging (CT/PET Scans, MRIs) | $150 Copay |
| Outpatient Services | |
| Surgery - Facility Fee (e.g., Ambulatory Surgery Center) | $150 (Chinese Hospital) / $450 (Other Facilities) |
| Outpatient Physician/Surgeon Fees | $0 Copay |
| Outpatient Visit | $0 Copay |
| Termination of Pregnancy | $0 Copay |
| Inpatient Services | |
| Facility Fee (e.g., Hospital Room) | $250 Copay Per Day (Chinese Hospital) $750 Copay Per Day (Other Facilities) (Up to the First 5 Days) |
| Inpatient Physician/Surgeon Fees | $0 Copay |
| Delivery and All Inpatient Services (Hospital Services) | $250 Copay Per Day (Up to the First 5 Days) |
| Delivery and All Inpatient Services (Professional Services) | $0 Copay |
| Emergency Health Coverage | |
| Emergency Room Services | $200 Copay |
| Emergency Room Physician Fee | $0 Copay |
| Urgent Care | $40 Copay |
| Ambulance Services | |
| Medical Transportation (Including Emergency and Non-emergency) | $100 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) | $15 Copay |
| Tier 2: Generic Drugs (90-Day Supply) Chinese Hospital Pharmacy, or Mail Order | $30 Copay |
| Tier 3: Non-Preferred Brand Drugs (30-Day Supply) | $25 Copay |
| Tier 3: Generic Drugs (90-Day Supply) Chinese Hospital Pharmacy, or Mail Order | $50 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 | 20% Coinsurance |
| Prosthetic Devices | 20% Coinsurance |
| Durable Medical Equipment | 20% Coinsurance |
| Mental Health Services | |
| Mental/Behavioral Health Outpatient Office Visits | $40 Copay |
| Mental/Behavioral Health Other Outpatient Items and Services | $40 Copay |
| Mental/Behavioral Health Inpatient Facility Fee | $250 Copay 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 | $40 Copay |
| Substance Use Disorder Other Outpatient items and Services | $40 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 | $0 Copay |
| Infusion Services | $0 Copay |
| Rehabilitation Services | $40 Copay |
| Habilitation Services | $40 Copay |
| Skilled Nursing Care | First 10 Days at No Charge, then $100 Copay Per Day |
| 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 |