| Benefit Description |
Participating Providers |
Non-Participating Providers |
| MONTHLY PREMIUM |
$80 |
| INPATIENT CARE |
| Inpatient Hospital Care |
$0 |
Days 1-60: initial deductible of $1,024
Days 61-90: $256
Days 91-150: $512 |
| Inpatient Mental Health Care |
$0 |
Days 1-60: initial deductible of $1,024
Days 61-90: $256
Days 91-150: $512 |
| Skilled Nursing Facility |
$0 |
20% coinsurance |
| Home Health Care |
$0 |
20% coinsurance |
| Hospice |
$0 |
$0 |
| OUTPATIENT CARE |
| Doctor Office Visits |
$0 |
20% coinsurance |
| Chiropractic Services |
$0 |
20% coinsurance |
| Podiatry Services |
$0 |
20% coinsurance |
| Outpatient Mental Health Care |
$0 |
20% coinsurance |
| Outpatient Substance Abuse Care |
$0 |
20% coinsurance |
| Outpatient Surgery |
$0 |
20% coinsurance |
| Emergency Ambulance Services |
$0 |
20% coinsurance |
| Emergency Care (waived if admitted) |
$50
|
| Urgently Needed Care |
$35 within and outside U.S. ($5,000 annual maximum)
|
| Outpatient Rehabilitation Services |
$0 Occupational, Physical, Speech Therapy; Medicare Limits Apply |
20% coinsurance Occupational, Physical, Speech Therapy; Medicare Limits Apply |
| *Benefit period applies. |
| OUTPATIENT MEDICAL SERVICES AND SUPPLIES |
| Durable Medical Equipment |
$0 |
20% coinsurance |
| Prosthetic Devices |
$0 |
20% coinsurance |
| Diabetes Self-Monitoring Training Supplies |
$0 |
20% coinsurance |
| Lab Services |
$0 |
20% coinsurance |
| Radiation Therapy |
$0 |
20% coinsurance |
| PREVENTIVE SERVICES |
| Bone Mass Measurement |
$0 |
20% coinsurance |
| Colorectal Screening Exam |
$0; unlimited exams |
20% coinsurance; unlimited exams |
| Immunizations |
$0 |
20% coinsurance |
| Mammograms |
$0; unlimited exams |
20% coinsurance; unlimited exams |
| Pap Smears and Pelvic Exams |
$0; unlimited exams |
20% coinsurance; unlimited exams |
| Prostate Cancer Screening Exams |
$0; unlimited exams |
20% coinsurance; unlimited exams |
| Routine Physical Exams (1 per year) |
$0 |
20% coinsurance |
| ADDITIONAL BENEFITS |
| Generic Prescription Drugs (up to a 30-day supply) |
$5 |
| Brand-Name Prescription Drugs (up to a 30-day supply) |
Preferred: $25
Non-Preferred: $50
Specialty 20% |
| Mail Order Prescription Drugs (up to a 90-day supply) |
2 Copay for 90 day supply; copay waived for generic |
|
Vision Services (1 pair eyewear/contacts
/year)
|
$0 |
20% coinsurance. |
| Health Club Membership |
Health Club Membership (including fitness classes) |
Not Available |
| Health/Wellness Education/Services |
Nutritional Training, Congestive Heart Program, Newsletter, Disease Management |
Not Available |
| Dental |
| Preventive Services |
$0 |
copays vary |
| Comprehensive Services |
copays vary |
copays vary |
| Dental Maximum |
$1000 maximum for preventive and comprehensive combined. |
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. |