| |
|
|
|
F
I
N
A
N
C
I
A
L |
Benefit |
In-Network |
Out-of-Network
Plans |
| |
|
|
96 1A(2)
96 1B(3) |
97 1A(2)
97 1B(3) |
97 2A(2)
97 2B(3) |
| |
Deductible |
None |
$50 Single; $150 Family |
$100 Single; $200 Family |
| |
Maximum
out-of-pocket cost (does not include charges in excess of allowed amount
or noncovered benefits) |
$1,000 Single;
$2,000 Family
copayment maximum |
None |
$1,000 per individual per calendar year |
| |
Maximum lifetime
benefit per participant or dependent |
Unlimited |
$1,000,000 |
|
(2) Reimbursed at
90th percentile; (3) Reimbursed at 70th percentile |
| |
P
R
E
V
E
N
T
I
V
E
C
A
R
E |
Routine physical
exams for children through age 18 |
No
cost |
Paid at 80% of UCR* |
| |
Routine
gynecological care for children through age 18 |
No
cost |
Paid at 80% of UCR* |
| |
Routine physical
exams for adults age 19 and older |
$10 copayment per visit |
Paid at 80% of UCR* |
| |
Routine
gynecological care for adults age 19 and older |
$10 copayment per visit |
Paid at 80% of UCR* |
| |
Immunizations |
No
cost |
Paid at 80% of UCR* |
|
|
Benefit |
In-Network |
Out-of-Network
Plans |
|
M
A
T
E
R
N
I
T
Y |
|
|
96 1A(2)
96 1B(3) |
97 1A(2)
97 1B(3) |
97 2A(2)
97 2B(3) |
| |
Obstetrical prenatal
care, delivery, and postnatal care for mother |
$10 copayment initial visit only(1) |
Paid at 100% of UCR(1) |
Paid at 83% of UCR*(1) |
|
(1) Prior
Authorization may be required; * After participant or dependent
meets deductible |
| |
I
N
P
A
T
I
E
N
T
C
A
R
E |
Room and board
(including maternity) |
No
cost(1) |
Generally paid so there are no out-of-pocket facility charges (private
room charge allowance paid at 100% for all A plans and at 50% up to $75
per day for B plans*)(1) |
| |
Physician's services
(including maternity, mental health, and substance abuse) |
No
cost |
Paid at 100% of UCR |
Paid at 80% of UCR* |
| |
Surgery |
No
cost(1) |
Paid at 100% of UCR(1) |
Paid at 83% of UCR*(1) |
| |
Restorative physical
and occupational therapy |
No
cost(1) |
Paid at 100% of facility charges to a maximum of 30 days(1);
then paid at 80% of facility charges*(1) |
|
|
Benefit |
In-Network |
Out-of-Network
Plans |
| |
E
R
|
|
|
96 1A(2)
96 1B(3) |
97 1A(2)
97 1B(3) |
97 2A(2)
97 2B(3) |
| |
At physician's
office or urgent care center |
$10 copayment per visit |
| |
At hospital
emergency room |
$25 copayment per
visit (waived if admitted) |
|
(2) Reimbursed at
90th percentile; (3) Reimbursed at 70th percentile |
| |
O
U
T
P
A
T
I
E
N
T
C
A
R
E
|
Office visits |
$10 copayment per visit |
Paid at 80% of UCR* |
| |
Chiropractic care |
$10 copayment per
visit(1) |
Paid at 80% of UCR*(1) |
| |
Acupuncture |
$20 copayment per
visit(1) |
Paid at 80% of UCR*(1) |
| |
Allergy treatment |
$10 copayment per visit |
Paid at 80% of UCR* |
| |
Restorative physical
& occupational therapy |
$10 copayment per
visit(1) |
Paid at 80% of UCR*(1) |
| |
Cardiac
rehabilitation |
$10 copayment per
visit(1) |
Paid at 80% of UCR*(1) |
| |
Radiology |
No
cost(1) |
Paid at 80% of UCR*(1) |
| |
Laboratory tests |
No
cost |
Paid at 80% of UCR* |
| |
Restorative speech
therapy for up to 60 consecutive days |
$10 copayment per
visit(1) |
Paid at 80% of UCR*(1) |
| |
Surgery (physician's
services) |
No
cost(1) |
Paid at 100% of UCR(1) |
Paid at 83% of UCR*(1) |
| |
Surgery (facility
charges) |
No
cost(1) |
Generally paid so there are no out-of-pocket charges to the patient(1) |
|
|
Benefit |
In-Network |
Out-of-Network
Plans |
| |
O
T
H
E
R
S
E
R
V
I
C
E
S |
|
|
96 1A(2)
96 1B(3) |
97 1A(2)
97 1B(3) |
97 2A(2)
97 2B(3) |
| |
Physician house
calls |
No
cost |
Paid at 80% of UCR* |
| |
Skilled home health
care services |
No
cost(1) |
Paid at 100 % of UCR for first 100 visits; Additional 40 visits paid at
80%*(1) |
| |
Hospice care (up to
210 days) |
No
cost(1) |
Paid at 100 % of charges(1) |
| |
Durable medical
equipment |
Paid at 80 % of cost of covered items to an unlimited maximum per
participant or dependent per calendar year(1) |
| |
In vitro
fertilization services (up to a $5,000 lifetime maximum benefit combined
with covered fertility drugs available through the Rx benefit |
No
cost(1) |
Paid at 100% of UCR(1) |
Paid at 80% of UCR*(1) |
|
(1) Prior
Authorization may be required; * After participant or dependent
meets deductible |
| |
M
E
N
T
A
L
H
E
A
L
T
H |
Outpatient mental
health (combined maximum for in- and out-of-network benefits) |
$10 copayment/ visit up to 20 visits/ calendar year(1);
more if necessary for certain biologically based conditions or severe
emotional disorders in children (1) |
Paid at 80% of UCR up to 20 visits per calendar year*(1); more if
necessary for certain biologically based conditions or severe emotional
disorders in children*(1) |
| |
Inpatient mental
health (combined maximum for in- and out-of-network benefits) |
No
cost(1) |
Paid at 100% of facility charges to a maximum of 30
days(1);
more days if necessary for certain biologically based conditions or severe
emotional disorders in children*(1) |
|
|
Benefit |
In-Network |
Out-of-Network
Plans |
| |
S
U
B
S
T
A
N
C
E
/
A
L
C
O
H
O
L |
|
|
96 1A(2)
96 1B(3) |
97 1A(2)
97 1B(3) |
97 2A(2)
97 2B(3) |
| |
Outpatient medical
rehabilitative care for substance abuse/alcohol addiction (combined
maximum for in- and out-of-network benefits) |
$10 copayment per visit up to 60 visits per year(1) |
Paid at 80% of UCR to a maximum of 60 visits per calendar year*(1) |
| |
Inpatient medical
rehabilitative care for substance abuse/alcohol addiction (combined
maximum for in- and out-of-network benefits) |
No
cost(1) |
Paid at 100% of facility charges(1) |
|
(2) Reimbursed at
90th percentile; (3) Reimbursed at 70th percentile |
