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Toll-Free Phone: Current Members: 1-866-572-9396 Non-members: 1-800-647-7328
TTY/TDD Phone: Current Members: 711 or 1-888-685-8480 Non-members: 1-800-387-1074
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Benefit Summary
| Annual Costs | 2010 Coverage |
|---|---|
Annual deductible |
$0 |
Annual out-of-pocket maximum |
$750/person |
Annual prescription drug deductible |
Does not apply |
| Medical Benefits | 2010 Coverage |
|---|---|
Ambulance services |
|
(air) |
$50/trip |
(ground) |
$50/trip |
Diagnostic tests, laboratory, and X-rays |
Enrollee pays $0 |
Durable medical equipment, supplies, and prostheses |
Enrollee pays $0 |
Emergency room (copay waived if admitted) |
$50 |
Hearing |
|
(routine annual exam) |
$10 |
(hardware) |
Enrollee pays any amount over $800 every 36 months for hearing aid and rental/repair combined |
Hospital services |
|
(inpatient) |
$150/day for 1-4 days |
(outpatient) |
Enrollee pays $0 |
Mental health care |
|
(outpatient) |
$10 |
Obstetric care |
|
(inpatient) |
Information unavailable, contact your plan |
(outpatient) |
Information unavailable, contact your plan |
Office visits |
$10 |
Physical, occupational, and speech therapy (per-visit cost for 60 visits/year combined) |
$10 |
Prescriptions |
|
tier 1 (retail pharmacy, 30-day supply) |
$10 |
tier 2 (retail pharmacy, 30-day supply) |
$25 |
tier 3 (retail pharmacy, 30-day supply) |
$40 |
tier 1 (mail order, 90-day supply) |
$20 |
tier 2 (mail order, 90-day supply) |
$50 |
tier 3 (mail order, 90-day supply) |
$80 |
Preventive care |
Enrollee pays $0 |
Spinal manipulations (per-visit cost for 10 visits/year) |
$10 |
Vision care |
|
(annual exam) |
$10 |
(glasses and contact lenses) |
Any amount over $150 every 12 months |
