Benefit Summary

This summary lists your share of the cost of Allowable Charges after the Plan pays benefits. See "Highlights of the Plan" for additional information about out-of-pocket limits and other plan features. See "Eligible Expenses" for more details about eligible expenses mentioned below. All benefits shown are determined based on Allowable Charges. However, a Preferred Provider Organization (PPO) or Out-of-Network (OON) provider may not accept the Plan's Allowable Charge as payment in full; in addition to your coinsurance percentage, you are responsible for any difference between the provider's full charge and the Allowable Charge. See "In-Network Plus (INP), Preferred Provider Organization (PPO), and Out-of-Network Providers (OON)" for more information.

Service

INP 

PPO

OON

Acupuncture1You pay $0You pay 20% after deductibleYou pay 40% after deductible
Advanced Imaging2
CT, PET, MRI, ultrasounds, etc.
You pay $0You pay 20% after deductibleYou pay 40% after deductible
Chiropractic Services3Not applicableYou pay 50% after deductibleNot covered
Diagnostic Tests & Standard Imaging2
X-ray, blood work, labs, stress test, mammogram
You pay $0You pay 20% after deductibleYou pay 40% after deductible
Durable Medical Equipment2
Rental or purchase, at Plan's option
You pay $0You pay 20% after deductibleYou pay 40% after deductible
Emergency Medical Transportation4
Ambulance, air transport, etc.
You pay $0You pay $0You pay $0
Emergency Room Services5

After you satisfy the deductible (required only for PPO or OON, not INP), then you pay the following, based on number of visits per calendar year for your family

  • Visits 1-2: You pay $150 copay (no coinsurance)
  • Visits 3-4: You pay $150 copay plus 20% coinsurance
  • 5 or more visits: You pay 50% coinsurance
If you are admitted, coinsurance applies to inpatient hospital services as noted below.
HealthCheck
To the extent available at your location
You pay $0 Not applicable Not applicable
Home Health Care1,2You pay $0 You pay 20% after deductible You pay 40% after deductible
Hospice2You pay $0You pay 20% after deductibleYou pay 40% after deductible
Infusion Services2,6You pay $0You pay 20% after deductibleYou pay 40% after deductible
Inpatient Hospital Services1,2,5
Includes facility fee for semiprivate room or intensive special care unit, physician/surgeon/anesthesiologist, and miscellaneous
You pay $0You pay 20% after deductibleYou pay 40% after deductible
Inpatient Skilled-Nursing Facility1,2You pay $0You pay 20% after deductibleYou pay 40% after deductible
Mental Health or Substance Abuse Services
Inpatient2 and outpatient
You pay $0You pay 20% after deductibleYou pay 40% after deductible
Office Visit - Primary Care
Family practitioner, general practitioner, internist, nurse practitioner, pediatrician
You pay $0You pay 20% after deductibleYou pay 40% after deductible
Office Visit - Specialist
Cardiologist, oncologist, dermatologist, OB/GYN, etc.
You pay $0You pay 20% after deductibleYou pay 40% after deductible
On-site Health Center
Includes video-conference consultations, to the extent available at your location
You pay $0Not applicableNot applicable
Outpatient Surgery/Procedure2
Includes facility fee and physician/surgeon/anesthesiologist
You pay $0You pay 20% after deductibleYou pay 40% after deductible
Preventive Care7
Approved screenings and immunizations
You pay $0You pay $0You pay 40% after deductible
Private-Duty Nursing2,8 You pay $0You pay 20% after deductibleYou pay 40% after deductible
Rehabilitation or Habilitation1
Speech, occupational, or physical therapy
You pay $0You pay 20% after deductibleYou pay 40% after deductible
Temporomandibular Joint (TMJ) Treatment9 You pay $0You pay 20% after deductibleYou pay 40% after deductible
Urgent Care CenterYou pay $0You pay 20% after deductibleYou pay 40% after deductible

 

Footnotes

1 Coverage for the following services is limited to the specified number of days or visits, combined for INP, PPO, and OON services:

  • Acupuncture: up to 25 visits per year
  • Home health care: up to 120 visits/year
  • Inpatient hospital or residential treatment center: up to 180 days for the same or a related condition
  • Skilled-nursing facility: up to 90 days/period of care
  • Speech, occupational, or physical therapy: up to 25 visits per year for each type of therapy

2 To avoid a benefit penalty, preauthorization must be obtained as soon as possible before receiving scheduled, nonemergency services or products, including dialysis, certain durable medical equipment, genetic testing, imaging tests (except X-rays and routine ultrasounds), infusion services, outpatient procedures, and home/portable oxygen. In addition, to avoid a benefit penalty, preauthorization must be obtained before inpatient admissions (or within two business days after unscheduled admissions), home health care, private-duty nursing, and hospice care. For a detailed listing of services and products for which preauthorization must be obtained, see "Appendix C: Services that Require Preauthorization." Failure to obtain preauthorization when required will result in a 25% benefit penalty (100% benefit penalty for transplants). As with all claims, any services determined not to be medically necessary will not be covered.

3 Coverage for chiropractic includes related office visits and eligible services billed and performed by the chiropractor, osteopath, or other medical professional who provides spinal manipulation services.

4 Benefits for air ambulance are not payable for charges in excess of 200% of the Medicare-approved amount.

5 Benefits for hospital observation status are limited to 24 consecutive hours.

6 The Plan pays 100% of Allowable Charges for preauthorized infusion services when the services are provided at an INP provider, an on-site Health Center or an alternate site (including at-home administration) arranged through Care Coordination Services.

7 To be covered, preventive care services must not exceed certain frequencies. Coverage for preventive care includes related office visits and services (such as lab tests and X-rays) if not billed separately and if the primary purpose of the visit is the preventive care.

8 Coverage for private-duty nursing is limited to a $25,000 lifetime maximum benefit (combined for INP, PPO, and OON services).

9 Coverage for TMJ is limited to surgical and non-appliance treatment, up to a $3,500 lifetime maximum (combined for INP, PPO, and OON services). This maximum amount also applies to any complications from TMJ treatment.

Other services may be covered at benefit levels that are different from the levels listed above. For example, see “Eligible Expenses” for information about coverage for cosmetic treatment to restore normal physical function.