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TTY/TDD Phone: Current Members: 1-800-685-8480 Non-members: 1-800-387-1074
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Benefit Summary
| Medical Benefit | Coverage |
|---|---|
|
Lifetime maximum |
None |
|
Annual deductible |
None |
|
Annual out-of-pocket maximum |
$750 per person per year |
|
Office and clinic visits |
$10 copay per visit |
|
Ambulance services |
|
|
(air) |
$50 copay |
|
(ground) |
$50 copay |
|
Bariatric Surgery (preauthorization required) |
Not covered |
|
Chemical dependency services (inpatient) |
Subject to inpatient hospital copay |
|
Chemical dependency services (outpatient) |
$10 copay per visit |
|
Diabetic education |
$10 copay per visit |
|
Diagnostic testing |
Plan pays 100% |
|
Durable medical equipment, supplies, and prostheses |
Plan pays 100% |
|
Emergency room (copay waived if admitted directly to hospital) |
$50 copay per visit |
|
Hearing |
|
|
(examination) |
$10 copay per exam |
|
(hardware) |
Plan maximum of $300 every 36 months |
|
Home health care |
Plan pays 100% |
|
Hospice care (including respite care) |
Plan pays 100% |
|
Hospital services |
|
|
(inpatient) |
$150 copay per day; maximum $600 per person per year |
|
(outpatient) |
Plan pays 100% |
|
Massage therapy |
Included in physical, occupational, and speech therapy benefit |
|
Mental health care |
|
|
(inpatient) |
Subject to inpatient hospital copay |
|
(outpatient) |
$10 copay per visit, up to 50 visits per year |
|
Neurodevelopmental therapy (for children ages 6 and younger) |
|
|
(inpatient) |
Subject to inpatient hospital copay |
|
(outpatient) |
$10 copay per visit |
|
Obstetric and well-newborn care |
|
|
(inpatient) |
Enrollee pays inpatient hospital copay for mother only |
|
(professional services) |
Covered in full |
|
Organ transplants |
|
|
(inpatient) |
Subject to inpatient hospital copay |
|
(professional) |
Plan pays 100% |
|
Physical, occupational, speech, and massage therapies |
|
|
(inpatient) |
Subject to inpatient hospital copay |
|
(outpatient) |
$10 copay per visit |
|
Prescription drugs, insulin, and disposable diabetic supplies |
Retail (up to a one-month supply): Formulary generic drugs, all insulin, and all disposable diabetic supplies: $10 copay per prescription or refill Medicare-approved diabetic supplies: plan pays 100% Formulary brand-name: $25 copay per prescription or refill Non-formulary $40 copay per prescription or refill Mail order (up to a 90-day supply): Formulary generic drugs, all insulin, and all disposable diabetic supplies: $20 copay per prescription or refill Medicare-approved diabetic supplies: plan pays 100% Formulary brand-name: $50 copay per prescription or refill Non-formulary $80 copay per prescription or refill |
|
Preventive care |
Plan pays 100% |
|
Radiation and chemotherapy services |
Plan pays 100% |
|
Skilled nursing facility care (150 days per benefit period) |
Subject to inpatient hospital copay |
|
Spinal manipulations |
With primary care provider referral $10 copay per visit Self-referred $10 copay per visit, up to 10 visits per calendar year |
|
Temporomandibular joint (TMJ) disorder |
Subject to applicable copay |
|
Vision |
|
|
(examinations) |
$10 copay per exam |
|
(hardware) |
Lenses: Plan pays 100% every 12 months Frames: $150 plan maximum Contact lenses (in lieu of lenses and frames): $150 plan maximum every 12 months |
