| Benefit Description |
Choice 1
(Within Physician Team) |
Choice 2
(Within Choices 65 Network) |
| INPATIENT CARE |
| Inpatient Hospital Care |
$0 |
$150/day (1-3 days) |
| Inpatient Mental Health Care |
$0 |
$0 |
| Skilled Nursing Facility |
$0 days 1-20
$50/day 21+ days |
$0 days 1-20
$50/day 21+ days |
| Home Health Care |
$0 |
10% ($500 OOP max) |
| Hospice |
$0 |
| OUTPATIENT CARE |
| PCP Office Visit |
$5 |
$25 |
Specialist Office Visit:
(includes: chiropractic podiatry services) |
$15 |
$25 |
Outpatient Behavioral/
Substance Abuse Care |
$10 (1-20 visits); 50% (21+ visits) |
| Outpatient Surgery |
$0 |
$150/visit |
| Ambulance Services |
$55 |
| Emergency Care (waived if admitted) |
$50 |
| Urgently Needed Care(within U.S.) |
$35 ($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) |
$5 (Medicare limits apply) |
$5 (Medicare limits apply) |
| OUTPATIENT MEDICAL SVCS/SUPP |
| Durable Medical Equipment |
10% coinsurance |
| Infusion Therapy |
0% coinsurance |
| Prosthetic Devices |
10% coinsurance |
20% 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 |
$0 |
| Colorectal Screening Exam |
$0 (1st exam) $5 for additional exams; unlimited |
$0 (1st exam) $5 for additional exams; unlimited |
| Immunizations |
$0 |
$0 |
| Mammograms |
$0 (1st exam) $5 for additional exams; unlimited |
$0 (1st exam) $5 for additional exams; unlimited |
| Pap Smears / Pelvic Exams |
$0 (1st exam) $5 for additional exams; unlimited |
$0 (1st exam) $5 for additional exams; unlimited |
| Prostate Cancer Screening Exams |
$0 (1st exam) $5 for additional exams; unlimited |
$0 (1st exam) $5 for additional exams; unlimited |
| Routine Physical Exams |
$5 |
Not Covered |
| TRANSPORTATION |
| Transportation |
$5 |
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. |
| Health Club Membership |
Health Club Membership (including fitness classes) |
| Health/Wellness Education/Services |
Nutritional Training, Smoking Cessation, Newsletter, Disease Management, Nurseline |
| Hearing Services |
$15 exam; discounts on hearing aids |
Vision Exam and Glasses
or Contact Lenses |
$15 for eye exam and $0 glasses or contacts |
| PHARMACY COVERAGE (PART D) |
| Generic Prescription Drugs |
$5 |
| Brand-name Prescription Drugs |
$25 Preferred;
$50 Non-Preferred (Not covered in the gap) |
| Specialty Drugs |
20% coinsurance
(Not covered in the gap) |
| Mail order |
2 Copays for 90 day supply; copay waived for generic from In Network Preferred Providers |
Notes:
* Up to 12 one-way rides per year. Eligibility for transportation to be established by Plan.
*Authorization necessary for certain services
Worldwide maximum of $5000 for Urgent and ER 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. |