Per Person: $3,500 In network $6,000 Out-of-network
Per Family: $7,000 In network $12,000 Out-of-network
Per Person: $6,000 In network $10,000 Out-of-network
Per Family: $12,000 In network $20,000 Out-of-network
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
| Common Medical Event | Services You May Need | What You Will Pay | Limitations, Exceptions, & Other Important Information | |
|---|---|---|---|---|
| Network Provider You will pay the least |
Out-of-Network Provider You will pay the most |
|||
| If you visit a health care provider’s office or clinic | Primary care visit to treat an injury or illness | Professional Non-Facility based services: $25 copay/per visit | 30% coinsurance after deductible | None |
| Facility based services: $25 copay/per visit Savings Plus Plan Benefit | ||||
| Specialist visit to treat an injury or illness | Professional Non-Facility based services: $50 copay/per visit | |||
| Specialist visit to treat an injury or illness | Professional Non-Facility based services: $50 copay/per visit | 30% coinsurance after deductible | None | |
| Facility based services: $50 copay/per visit Savings Plus Plan Benefit | ||||
| Preventive care/screening/ immunization | No Charge | 30% coinsurance after deductible | You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. | |
| If you have a test | Diagnostic test (x-ray, blood work) | Lab & Pathology & Radiology: Office or Independent Lab: $25 copay/per visit | 30% coinsurance after deductible | None |
| Lab & Pathology & Radiology: Facility based services: 15% coinsurance after deductible Savings Plus Plan Benefit | ||||
| Imaging (CT/PET scans, MRIs) | Office or Independent Lab: 15% coinsurance after deductible | 30% coinsurance after deductible | Sleep Studies are covered in the home at Office or Independent Lab Cost Share. Preauthorization is required or benefit reduces by 20%. | |
| If you need drugs
to treat your
illness or
condition More information about prescription drug coverage is available at www.carelonrx.co m or call 1-833-271-2374 |
Generic drugs (Tier 1) | 30 day supply: Lesser of cost of medication or $10 copay 31-90 day supply: Lesser of cost of medication or $25 copay | Not Covered | Covers 30 day supply
(retail), 31-90 day supply
(retail or mail order). Includes contraceptive drugs & devices obtainable from a pharmacy. No charge for preferred generic FDA-approved women's contraceptives in-network. Review your formulary for prescriptions requiring precertification or step therapy for coverage. No Charge for ACA mandated generic medications. |
| Preferred brand drugs (Tier 2) | 30 day supply: $25 copay (Deductible waived) 31-90 day supply: $50 copay (Deductible waived) | |||
| Non-preferred brand drugs (Tier 3) | 30 day supply: $50 copay (Deductible waived) 31-90 day supply: $125 copay (Deductible waived) | |||
| Specialty drugs (Tier 4) | All Specialty Drugs are Excluded: Contact Payer Matrix for assistance at 1-877-305-6202 9am - 8pm EST M-F. | |||
| If you have outpatient surgery | Facility fee (e.g., ambulatory surgery center) | 15% coinsurance after deductible Savings Plus Plan Benefit | 30% coinsurance after deductible | Preauthorization is required for some services. If Preauthorization required but not obtained benefit reduces by 20% . |
| Physician/ surgeon fees | 15% coinsurance after deductible Savings Plus Plan Benefit | 30% coinsurance after deductible | None | |
| If you need immediate medical attention | Emergency room care | $250 copay/per visit deductible waived Savings Plus Plan Benefit | ER copay is waived if admitted as inpatient. All facilities are covered as innetwork subject to meeting “emergency” criteria. | |
| Emergency medical Transportation | $15 coinsurance after deductible Savings Plus Plan Benefit | All facilities are covered as in-network subject to meeting “emergency” criteria. | ||
| Urgent care | $50 copay/per visit deductible Waived | 30% coinsurance after deductible | None | |
| If you have a hospital stay | Facility fee (e.g., hospital room) | 15% coinsurance after deductible Savings Plus Plan Benefit | 30% coinsurance after deductible | Preauthorization is required or benefit reduces by $1,000 . |
| Physician/surgeon fees | 15% coinsurance after deductible Savings Plus Plan Benefit | 30% coinsurance after deductible | None | |
| If you need help recovering or have other special health needs | Home health care | 15% coinsurance after deductible | 30% coinsurance after deductible | Limited to 60 visits per calendar year. Preauthorization is required or benefit reduces by 20% . |
| Rehabilitation services | Professional Non-Facility based services: $25 copay/per visit | 30% coinsurance after deductible | Maximum 60 visits per calendar year. Combined limit for Rehabilitative / Habilitative services includes physical therapy, speech therapy, and occupational therapy. Combined In- Network and Out-of-Network limit. Preauthorization is required or benefit reduces by 20% . | |
| Facility based services: $25 copay/per visit Savings Plus Plan Benefit | ||||
| Habilitation services | Professional Non-Facility based services: $25 copay/per visit | 30% coinsurance after deductible | ||
| Facility based services: $25 copay/per visit Savings Plus Plan Benefit | ||||
| Skilled nursing care | 15% coinsurance after deductible Savings Plus Plan Benefit | 30% coinsurance after deductible | Maximum 60 days per calendar year. Combined limit with Inpatient Physical Medical Rehabilitation. Combined In- Network and Out-of-Network limit. Preauthorization is required or benefit reduces by $1,000 . | |
| Durable medical equipment | 15% coinsurance after deductible | 30% coinsurance after deductible | Preauthorization is required for items. If Preauthorization required but not obtained benefit reduces by 20% . | |
| Hospice services | Home Setting: coinsurance after deductible | 30% coinsurance after deductible | Preauthorization is required or benefit reduces by $1,000 . | |
| Facility Setting: 15% coinsurance after deductible Savings Plus Plan Benefit | ||||
| If your child needs dental or eye care | Children’s eye exam | Professional Non-Facility based services: $50 copay/per visit | 30% coinsurance after deductible | Children eye exam non PPACA limited to 1 exam every 24 months. PPACA mandated service: One vision screening for children 3-5 years is covered as a preventive service. Cost sharing does not apply for preventive services. |
| Facility based services: $50 copay/per visit Savings Plus Plan Benefit | ||||
| Children’s glasses | Not Covered | Not Covered | No coverage for glasses. | |
| Children’s dental check-up | Not Covered Except for ACA mandated services | Not Covered | Dental caries fluoride application for infants and children up to 5 years are covered as preventive services. Cost sharing does not apply for preventive services. | |