Individuals and Families, $50 Copayment Plan
| Medical calendar-year deductible (Individual/Family) |
None |
| Pharmacy calendar-year deductible |
None |
| Annual out-of-pocket maximum (Individual/Family) |
$3,500 / $7,000 |
| Lifetime benefit maximum |
None |
| Primary and specialty care visits (includes routine and urgent care appointments) |
$50 per visit |
| Well-child visits from 0 to 23 months |
$15 per visit |
| Family planning visits |
$50 per visit |
| Scheduled prenatal care and first postpartum visit |
$15 per visit |
| Eye exams |
$50 per visit |
| Hearing tests |
$50 per visit |
| Physical, occupational, and speech therapy visits |
$50 per visit |
| Outpatient surgery |
$250 per procedure |
| Allergy injection visits |
$5 per visit |
| Vaccines (immunizations) |
No charge |
| Most X-rays and lab tests |
$10 per encounter |
| Individual visits |
$50 per visit |
| Group visits |
No charge |
| Room and board, surgery, anesthesia, X-rays, lab tests, and medications |
$500 per day |
| Emergency Department visits |
$150 per visit
($150 copayment is waived if admitted directly to the hospital)
|
| Emergency ambulance services |
$300 per trip |
| Most prescription drugs are not covered |
| DME used in the home in accord with our DME formulary |
Not covered |
|
| Inpatient psychiatric care |
| Inpatient psychiatric care |
$500 per day (up to 30 days per calendar year) |
|
| Outpatient visits |
| Individual visits |
$50 per visit
(up to a total of 20 individual/group visits per calendar year) |
| Group therapy visits |
$25 per visit
(up to a total of 20 individual/group visits per calendar year)
Up to 20 additional group therapy visits that meet
Medical Group criteria in the same calendar year |
|
| Note: Visit
and day limits do not apply to severe mental illness and serious
emotional disturbances of children as described in the "Benefits and Cost Sharing" section of the Membership Agreement.
|
| Inpatient detoxification |
$500 per day |
| Outpatient individual therapy visits |
$50 per visit |
| Outpatient group therapy visits |
$5 per visit |
| Transitional residential recovery services (up to 60 days per calendar year, not to exceed 120 days in any five-year period) |
$100 per admission |
| Home health care (up to 100 two-hour visits per calendar year) |
No charge |
| Skilled Nursing Facility care |
No charge (up to 100 days per benefit period) |
| Hospice care |
No charge |
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