The table below lists costs for common services for each It's Your Choice plan design option. Your Certificate of Coverage details all of your benefits.
In-Network Services Local Traditional, & Local Access Plan | Out-of-Network Services Local Access Plan | |
|---|---|---|
| Annual Medical Deductible | No deductible | $500 individual / $1,000 family When an individual within a family plan meets the $500 deductible, coinsurance will apply to covered medical services Medical deductible does not apply to prescription drugs |
| Annual Medical Coinsurance | None Plan pays 100% for most services. Exceptions: durable medical equipment, adult hearing aids, and cochlear implants | After deductible, plan pays 80%; you pay 20% coinsurance up to Out-of-Pocket Limit (OOPL) |
| 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 | None |
| Routine, preventive services as required by federal law | Plan pays 100% For details, visit | After deductible, plan pays 80%; you pay 20% coinsurance up to OOPL |
| Illness/injury related services | Plan pays 100% | After deductible, plan pays 80%; you pay 20% 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 | You pay $60 copay per visit; the in-network deductible applies to services after the copay |
| Vision Exam | Routine exam: Plan pays 100% (one per year) Illness or injury exam: Plan pays 100% | Routine exam: No benefit Illness or injury exam: After deductible, plan pays 80% for adults or children; you pay 20% coinsurance up to OOPL |
| Hearing Exam | Plan pays 100% | After deductible, plan pays 80% only when exam is for illness or disease; you pay 20% coinsurance up to OOPL |
| Hearing Aid (per ear, every 3 years) | Adults: Plan pays 80% up to $1,000 benefit limit; you pay 20% coinsurance for the first $1,000 and the full cost after Children: Plan pays 100% | Adults: No benefit Children: After deductible, plan pays 80%; you pay 20% coinsurance up to OOPL |
| Cochlear Implants | Adults: Plan pays 80%; you pay 20% coinsurance (not up to OOPL) for device, surgery, and 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 80%; you pay 20% coinsurance up to OOPL for device, surgery, and follow-up sessions |
| Durable Medical Equipment | Plan pays 80%; you pay 20% coinsurance up to $500 OOPL per person | After deductible, plan pays 80%; you pay 20% coinsurance up to OOPL |
| Physical/Speech/Occupational Therapy | 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 80%; you pay 20% 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) | Plan pays 100% for 120 days per benefit period | After deductible, plan pays 80%; you pay 20% coinsurance up to OOPL for 120 days per benefit period |
| Home Health (non-custodial care) | Plan pays 100% for 50 visits per year Plan may approve an additional 50 visits | After deductible, plan pays 80%; you pay 20% 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: Plan pays 100% | Outpatient, inpatient, and covered transitional services: After deductible, plan pays 80%; you pay 20% coinsurance up to OOPL |
| Transplants | Plan pays 100% | After deductible, plan pays 80%; you pay 20% 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 Local Traditional Plan, a referral is required for any benefits to be covered out-of-network | Not required |
| Oral Surgery | Plan pays 100% | After deductible, plan pays 80%; you pay 20% coinsurance up to OOPL |
| Telemedicine Services | Varies by service type. See Telemedicine page | Varies by service type. See Telemedicine page |