| Benefit Description |
Choice 1 (Within Physician Team) |
Choice 2 (Within Secure Health Network) |
| INPATIENT CARE |
| Inpatient Hospital Care |
$0 |
$150/day (1-3 days) |
| Inpatient Mental Health Care |
$0 |
| Skilled Nursing Facility |
$0 days 1-20; $50/day 21+ days |
| Home Health Care |
$0 |
10% ($500 OOP max) |
| Hospice |
$0 |
| OUTPATIENT CARE |
| Primary Care Physician Office Visit |
$0 |
$25 |
| Specialist Office Visit (includes chiropractic podiatry services) |
$0 |
$25 |
| Outpatient Mental Health / Substance Abuse Care |
$10 (1-20 visits); 50% (21+ visits) |
| Outpatient Surgery / Surgery |
$0 |
$150 visit |
| Ambulance Services |
$50 |
| Emergency Care |
$50 |
| Urgently Needed Care (inside and outside U.S.) |
$10 ($5,000 annual maximum) |
| Outpatient Rehabilitation Services |
$0 for Occupational Therapy (Medicare limits apply) $0 for physical speech/language therapy (Medicare limits apply) |
| OUTPATIENT MEDICAL SERVICES AND SUPPLIES |
| Durable Medical Equipment |
$0 |
5% coinsurance |
| Infusion Therapy |
$0 |
| Prosthetic Devices |
$0 |
5% coinsurance |
| Diabetes Self-Monitoring Training Supplies |
$0 |
| Diagnostic Tests, X-Rays and Lab Services |
$0 |
| Visitor / Travel Benefit |
Not applicable |
| PREVENTIVE SERVICES |
| Bone Mass Measurement |
$0 |
| Colorectal Screening Exams (unlimited) |
$0 |
| Immunizations (Pneumonia, Flu and Hepatitis) |
$0 |
| Mammograms (unlimited) |
$0 |
| Pap Smears and Pelvic Exams (unlimited) |
$0 |
| Prostate Cancer Screening Exams (unlimited) |
$0 |
| Routine Physical Exams (one exam/year) |
$0 |
Not Covered |
| OUTPATIENT PRESCRIPTION DRUGS (up to 30-day supply) - copays may vary based on member's Extra Help status* |
| Generic Prescription Drugs (Unlimited) |
Cost sharing based on LIS |
| Brand-Name Prescription Drugs (Unlimited) |
Cost sharing based on LIS |
| Specialty Drugs (unlimited) |
Cost sharing based on LIS |
| ADDITIONAL BENEFITS |
| Hearing Services (diagnostic hearing exam) |
$0 |
| Discounts on routine exams and hearing aids |
| Vision (Medicare covered eye exam) |
$0 exam; $0 glasses or contacts |
$15 exam; $0 glasses or contacts |
| Health Club Membership |
Health Club Membership (including fitness classes) |
| Health/Wellness Education/Services |
Nutritional Training, Newsletter, Disease Management, Nurseline, Smoking Cessation |
| Transportation Services |
$5 (12 one-way trips/year) |
| Dental Services (up to $1,000/year) |
$0 for selected preventive dental service including oral exam, cleaning, dental x-rays |
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. |