Per Person: $5,000
Per Family: $7,500
Per Person: $7,500
Per Family: $1,200
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 | Out-of-Network Provider | |||
| If you visit a healthcare provider’s office or clinic | Primary care visit to treat an injury or illness | Professional
Non-Facility
based services:
20% coinsurance
after deductible Facility-based services: 20% coinsurance after deductible Savings Plus Plan Benefit |
50% coinsurance after deductible | None |
| Specialist visit to treat an injury or illness | Professional Non-Facility based services:
20% coinsurance after deductible Facility based services: 20% coinsurance after deductible Savings Plus Plan Benefit |
50% coinsurance after deductible | None | |
| Preventive care/screening/ immunization | No charge | Not Covered | 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/
X-ray Office
Setting or
Independent Lab:
20% coinsurance
after deductible Lab/pathology/ X-ray Facility based services: 20% coinsurance after deductible Savings Plus Plan Benefit |
50% coinsurance after deductible | None |
| Imaging (CT/PET scans, MRIs) | Office Setting or
Independent
Lab: 20% coinsurance after deductible Facility based services: 20% coinsurance after deductible |
50% coinsurance after deductible | Preauthorization is required or benefit will be reduced by 20% for outpatient services. | |
|
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.carelonrx.com or call 1-833-271-2374 |
Generic drugs (Tier 1) | After Plan
Deductible is
Met: 30 day supply: $10 copay 31-90 day supply: $25 copay |
After Plan
Deductible is
Met: 30 day supply: $10 copay Retail |
Plan Deductible Applies 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) | After Plan
Deductible is
Met: 30 day supply: $35 copay 31-90 day supply: $87.50 copay |
After Plan
Deductible is
Met: 30 day supply: $35 copay Retail |
||
| Non-preferred brand drugs (Tier 3) | After Plan
Deductible is
Met: 30 day supply: $70 copay 31-90 day supply: $175 copay |
After Plan
Deductible is
Met: 30 day supply: $70 copay Retail |
||
| 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) | 20% coinsurance after deductible Savings Plus Plan Benefit | 50% coinsurance after deductible | Preauthorization is required or benefit will be reduced by 20% for outpatient services. |
| Physician/surgeon fees | 20% coinsurance after deductible Savings Plus Plan Benefit | 50% coinsurance after deductible | None | |
| If you need immediate medical attention | Emergency room care | 20% coinsurance after deductible Savings Plus Plan Benefit | All facilities are covered as in-network subject to meeting “emergency” criteria. Network deductible applies for Out-of-Network | |
| Emergency medical transportation | 20% coinsurance after deductible Savings Plus Plan Benefit |
All facilities are covered as in-network subject to meeting “emergency” criteria. Network deductible applies for Out-of-Network | ||
| Urgent care | 20% coinsurance after deductible | 50% coinsurance after deductible | None | |
| If you have a hospital stay | Facility fee (e.g., hospital room) | 20% coinsurance
after deductible Savings Plus Plan Benefit |
50% coinsurance after deductible | Preauthorization is required or benefit will be reduced by $1,000. |
| Physician/ surgeon fees | 20% coinsurance
after deductible Savings Plus Plan Benefit |
50% coinsurance after deductible | None | |
| If you need mental health, behavioral health, or substance abuse services | Outpatient services | Professional Non-Facility based services: 20% coinsurance after deductible | 50% coinsurance after deductible | None |
| Facility based services: 20% coinsurance after deductible Savings Plus Plan Benefit |
||||
| Inpatient services | 20% coinsurance after deductible Savings Plus Plan Benefit |
50% coinsurance after deductible | Preauthorization is required or benefit will be reduced by $1,000. | |
| If you are pregnant | Office visits | Professional Non-Facility based
services: 20% coinsurance after deductible Facility based services: 20% coinsurance after deductible Savings Plus Plan Benefit |
50% coinsurance after deductible | Cost sharing does not apply to certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Maternity Care for a Dependent Child is not covered. Preauthorization is required for stays longer than 48 hours for vaginal birth or 96 hours for cesarean birth if Preauthorization is not obtained benefit reduces by $1,000. |
| Childbirth/delivery professional services | 20% coinsurance after deductible Savings Plus Plan Benefit |
50% coinsurance after deductible | ||
| Childbirth/delivery facility services | 20% coinsurance after deductible Savings Plus Plan Benefit |
50% coinsurance after deductible | ||
| If you need help recovering or have other special health needs | Home health care | 20% coinsurance after deductible | 50% coinsurance after deductible | Maximum 100 visits per calendar year. Preauthorization is required or benefit will be reduced by 20% for outpatient services. |
| Rehabilitation services | Professional Non-Facility based services: 20% coinsurance after deductible Facility based services: 20% coinsurance after deductible Savings Plus Plan Benefit |
50% coinsurance after deductible | Preauthorization is required or benefit reduces by 20%. Out of Network Physical/Occupational therapy is not covered. Includes physical therapy, speech therapy, and occupational therapy. | |
| Habilitation services | Professional Non-Facility based services: 20% coinsurance after deductible | 50% coinsurance after deductible | ||
| Facility based services: 20% coinsurance after deductible Savings Plus Plan Benefit | ||||
| Skilled nursing care | 20% coinsurance
after deductible Savings Plus Plan Benefit |
50% coinsurance after deductible | Maximum 100 visits per
calendar year. Preauthorization is required or benefit will be reduced by $1,000. |
|
| Durable medical equipment | 20% coinsurance after deductible | Not Covered | Preauthorization is required for items over $1,000 or benefit reduces by 20%. | |
| Hospice services | Home Setting: 20% coinsurance after deductible |
50% coinsurance after deductible | Maximum 210 days per
calendar year. Preauthorization is required or benefit will be reduced by $1,000. |
|
| Facility based
services: 20% coinsurance after deductible Savings Plus Plan Benefit |
||||
| If your child needs dental or eye care | Children’s eye exam | Not Covered Except for ACA mandated services | Not Covered | One vision screening for children 3-5 years is covered as a preventive service Cost sharing does not apply for preventive services. |
| Children’s glasses | Not Covered | Not Covered | No coverage for glasses | |
| Children’s dental check-up | Not Covered Except for ACAmandated 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. | |