The table below lists costs for common services for each plan design. Your Certificate of Coverage details all of your benefits.
In-Network Services Local Deductible & Local Access Deductible Plan | Out-of-Network Services Local Access Deductible Plan | |
|---|---|---|
| Annual Medical Deductible | $500 individual / $1,000 family When an individual within a family plan meets the $500 deductible, benefits apply as described below Deductible applies to annual out-of-pocket limit (OOPL) Prescriptions do not count toward your deductible | $1,000 individual / $2,000 family When an individual within a family plan meets the $1,000 deductible, benefits apply as described below Deductible applies to annual out-of-pocket limit (OOPL) Prescriptions do not count toward your deductible |
| Annual Medical Coinsurance | 100% until deductible met After deductible, $0 except for durable medical equipment, adult hearing aids, and cochlear implants | After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL Applies to medical services |
| Annual Medical Maximum Out-of-Pocket Limit (OOPL) | $9,200 individual / $18,400 family for federally required essential health benefits Only applies to durable medical equipment and emergency room copays | $4,000 individual / $8,000 family (includes deductible) |
Routine, preventive services as required by federal law | $0 Plan pays 100% | After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL |
| Illness/injury-related services | After deductible, plan pays 100% | After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL |
Emergency Room Copay Waived if admitted as an inpatient directly from the emergency room or for observation for 24 hours or longer | You pay $60 copay per visit Deductible and coinsurance applies to services beyond the copay | You pay $60 copay per visit, after copay in-network deductible and 30% coinsurance up to OOPL |
| Vision Exam | Routine exam: After deductible, plan pays 100% for one routine eye exam per year Illness or injury: After deductible, plan pays 100% for adults or children | Routine exam: No benefit Illness or injury: After deductible, plan pays 70% for adults or children; you pay 30% coinsurance up to OOPL |
| Hearing Exam | After deductible, plan pays 100% | After deductible, plan pays 70% only when exam is for illness or disease; you pay 30% coinsurance up to OOPL |
| Hearing Aid (per ear) | Every 3 years: Children: After deductible, plan pays 100% | Every 3 years: Children: After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL |
| Cochlear Implants | Adults: After deductible, you pay 20% coinsurance (not up to OOPL) for device, surgery, follow-up sessions; plan pays 100% for hospital charge for surgery Dependents under age 18: Plan pays 100% for all services | Dependents under age 18: After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL for device, surgery, follow-up sessions |
| Durable Medical Equipment | After deductible, plan pays 80%; you pay 20% coinsurance up to $500 OOPL per person | After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL |
| Physical/Speech/Occupational Therapy | After deductible, plan pays 100% for a combined 50 visits per year (amongst all therapies) Plan may approve an additional 50 visits per therapy type per year | After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL for a combined 50 visits per year (amongst all therapies) Plan may approve an additional 50 visits per therapy type per year |
| Skilled Nursing Facility (non-custodial care) | After deductible, plan pays 100% for 120 days per benefit period | After deductible, plan pays 70% for 120 days per benefit period; you pay 30% coinsurance up to OOPL |
| Home Health (non-custodial care) | After deductible, plan pays 100% for 50 visits per year Plan may approve an additional 50 visits | After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL for 50 visits per plan year Plan may approve an additional 50 visits |
| Mental Health/Alcohol & Drug Abuse | Outpatient, inpatient, and covered transitional services: After deductible, plan pays 100% | Outpatient, inpatient, and covered transitional services: After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL |
| Transplants | After deductible, plan pays 100% | After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL |
| Precertification for hospitalizations, high-tech radiology, and low back surgery | Varies by plan. See plan descriptions and contact your plan | Contact your plan |
| Referrals | In-network: Varies by plan. See plan descriptions and contact your plan For the Local Deductible Plan, a referral is required for any benefits to be covered out-of-network | Not required |
| Oral Surgery | After deductible, plan pays 100% | After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL |
| Telemedicine Services | Varies by service type. See Telemedicine page | Varies by service type. See Telemedicine page |