|
Monthly Premium
|
$0
|
|
Maximum Out-of-Pocket Expense
|
$4,800
|
|
SERVICES / BENEFITS
|
In-Network
|
Out-of-Network
|
|
Primary Care Physician Office
Visit
|
$15 |
20% |
|
Specialist Office Visit
|
$30 |
20% |
|
Annual Routine Physical Exam
|
$0 |
20% |
|
Preventive Services
(mammograms, prostate screening, cholesterol screening,
pap smears, immunizations)
|
$0 |
20% |
|
Diagnostic Radiology Services
|
20% |
20% |
|
X-Ray
|
$0 |
20% |
|
Inpatient Hospitalization
|
$250/day
(days 1-5) |
$200/day |
|
Urgent Care Center
|
$25 |
$25 |
|
Emergency Room
|
$50 |
$50 |
|
Laboratory Services
|
$0 |
20% |
|
Durable Medical Equipment
|
20% |
20% |
|
Home Health Care
|
$0 |
20% |
|
Rehabilitation Services
(outpatient)
|
$30 |
20% |
|
Semi-Annual Dental Services (oral
exams, cleanings, dental x-rays)
|
$0 |
$0 |
|
Routine Vision Exam
|
$15 |
20% |
|
Diagnostic / Treatment Vision
Exam
|
$15 |
20% |
|
Hearing Exam (annual)
|
$15 |
20% |
|
Prescription Drugs
Tier 1
Tier 2
Tier 3
Tier 4
|
$7
$35
$70
25%
|
$73
$353
$703
25%3
|
|
A coordinated care plan with a Medicare Advantage contract. The benefit information provided herein is a brief summary, but not a comprehensive description of available benefits. Additional information about benefits is available to assist you in making a decision about your coverage
For members of the PPO plan, with the exception of emergencies or urgent care, it may cost more to get care from out-of-network providers.
|