| Benefit Description |
Choice 1
(Within Physician Team) |
Choice 2
(Within Choices Plus Network) |
Choice 3
(Out-of-Network) |
| INPATIENT CARE |
| Inpatient Hospital Care |
$0 |
$150/day (days 1-3) |
Days 1-60: initial deductible of $1,024
Days 61-90: $256
Days 91-150: $512 |
| Inpatient Mental Health Care |
$0 |
$0 |
Days 1-60: initial deductible of $1,024
Days 61-90: $256
Days 91-150: $512 |
| Skilled Nursing Facility |
$0 days 1-20;$50/day 21+ days |
20% |
| Home Health Care |
$0 |
10% ($500 OOP max) |
20% |
| OUTPATIENT CARE |
| PCP Office Visit |
$5 |
$25 |
20% |
| Specialist Office Visit(includes: chiropractic podiatry services) |
$10 |
$25 |
20% |
| Outpatient Mental Health / Substance Abuse Care |
$10 for visit 1-20; 50% of Medicare approved amounts for 21 and beyond visits |
20% |
| Outpatient Surgery |
$0 |
$150 |
20% |
Emergency Care
(waived if admitted) |
$50 |
$50 |
$50 |
| Ambulance Service |
$0 |
$0 |
20% |
Urgently Needed Care
(within U.S.) |
$25 ($5,000 annual maximum)
|
| Urgently Needed Care(outside of U.S.) |
$50 ($5,000 annual maximum)
|
| Outpatient Rehabilitation Services(Includes: Occupational, Physical, and Speech Therapy) |
$0 (Medicare limits apply) |
$0 (Medicare limits apply) |
20% (Medicare limits apply) |
| OUTPATIENT MEDICAL SVCS/SUPP |
| Durable Medical Equipment |
5% |
10% |
20% |
| Infusion Therapy |
$0 |
$0 |
20% |
| Prosthetic Devices |
5% |
20% |
20% |
| Diabetes Self-Monitoring Training and Supplies |
$0 |
$0 |
20% |
| Diagnostic Tests, X-Rays and Lab Services |
$0 |
$0 |
20% |
| PREVENTIVE SERVICES |
| Bone Mass Measurement |
$0 |
$0 |
20% |
| Colorectal Screening Exams |
$0 (1st exam) $5 for additional exams; unlimited |
$0 (1st exam) $5 for additional exams; unlimited |
20% |
| Immunizations |
$0 |
$0 |
20% |
| Mammograms |
$0 (1st exam) $5 for additional exams; unlimited |
$0 (1st exam) $5 for additional exams; unlimited |
20% |
| Pap Smears and Pelvic Exams |
$0 (1st exam) $5 for additional exams; unlimited |
$0 (1st exam) $5 for additional exams; unlimited |
20% |
| Prostate Cancer Screening Exams |
$0 (1st exam) $5 for additional exams; unlimited |
$0 (1st exam) $5 for additional exams; unlimited |
20% |
| Routine Physical Exams |
$5 |
Not Covered |
Not Covered |
| TRANSPORTATION |
| Transportation |
$5 up to 12 one way trips |
Not Covered |
| ADDITIONAL BENEFITS |
| Dental Services |
$0 for selected preventive dental service including oral exam, cleaning, dental x-rays. (Annual Max of $1000 applies) $50 deductible for comprehensive coverage. |
| Hearing Services |
100% for routine hearing exams $10 for each Medicare covered diagnostic hearing exam |
100% for routine hearing exams / 20% for each Medicare covered diagnostic hearing exam |
| Vision Services |
$15 for routine exam (1 per year); $0 (for 1 pair of glasses or contact lenses per year) |
100% for routine hearing exams / 20% for each Medicare covered diagnostic hearing exam |
| Health Club Membership |
Health Club Membership(including fitness classes) |
Not Covered |
| Health/Wellness Education |
Nutritional Training, Newsletter,Disease Management |
Not Covered |
| PHARMACY COVERAGE (PART D) |
| Generic Drugs |
$5 for a 30-day supply |
| Preferred Brand-Name Drugs |
$25 for a 30-day supply |
| Non-Preferred Brand-Name Drugs |
$50 for a 30-day supply |
| Specialty Drugs |
20% for a 30-day supply |
| Mail Order Prescription Drugs(up to a 90-day supply) |
2 Copay for 90 day supply; copay waived for generic from In Network Preferred Providers |
Please note:
This grid is merely an overview of the changes and should not be used as a replacement for the Summary of Benefits or Evidence of Coverage. |