| |
Value Plans |
Annual Deductible
Individual/Family |
Value 1000 - $1,000/$3,000 |
Value 2500 - $2,500/$7,500 |
Value 5000 - $5,000/$15,000 |
Value 7500 - $7,500/$22,500 |
Annual Out-of-Pocket Maximum
Individual/
Family |
Value 1000 - $6,000/$18,000 |
Value 2500 - $6,000/$18,000 |
Value 5000 - $9,000/$27,000 |
Value 7500 - $11,000/$33,000 |
| Essential Health Benefit Maximum |
$1,250,000 plan year aggregate limit |
| Accidental Injury Benefit |
The deductible is waived for all covered
services, except for chiropractic services, required to treat an accidental
injury within 90 days of injury. |
After meeting your deductible, you pay the following
amounts for covered services:
(The deductible is waived for some covered services. These services are marked with †. *Limitations apply. See your Plan Contract for details |
| Preventive Care |
In-Plan |
Out-of-Plan |
| Periodic health exams, well-baby care |
Covered in full † |
50% † |
| Routine immunizations/shots |
Covered in full † |
50% † |
| Mammograms |
Covered in full † |
50% |
| Gynecological exams, Pap tests |
Covered in full † |
50% † |
|
Physician/Provider Services |
| Office visits |
$30 copay † |
50% † |
| Office visits to specialists |
30% |
50% |
| Inpatient hospital visits, surgery and anesthesia |
30% |
50% |
| Hospital Services |
| Inpatient & observation care |
30% |
50% |
| Maternity care |
30% |
50% |
| Routine newborn nursery care |
30% |
50% |
| Rehabilitative care |
30% |
50% |
| Emergency/Urgent care |
| Emergency services |
$250 copay |
| Urgent care visits |
$30 copay † |
50% † |
Emergency transportation
|
30% |
50% |
| Outpatient Diagnostic Services |
| X-ray; lab services |
30% |
50% |
| Imaging services (PET, CT, MRI) |
30% |
50% |
| Other Covered Services |
| Medical & diabetes supplies |
30% |
50% |
| Outpatient surgery, radiation therapy, chemotherapy |
30% |
50% |
| Mental health and alcohol treatment |
30% |
50% |
| Prescription Drugs |
| Covered at participating pharmacies at the In-Plan benefit only |
Generic drugs & Brand-name drugs -50% † |
| Alternative care services |
| Acupuncture, chiropractic care, massage therapy and dietitian services |
Receive 25% off provider rates through the Choose Healthy network. |
| Routine Vision Services (administerd by VSP) |
Routine Vision Exam
(covered once per 12 months) |
$30 copay |
Covered up to $29 |
Frames
(covered once per 24 months) |
Covered up to $120 |
Covered up to $33 |
| Basic Lenses (covered once per 24 months)
|
| Single |
Covered in full |
Covered up to $28 |
| Bifocal |
Covered in full |
Covered up to $42 |
| Trifocal |
Covered in full |
Covered up to $56 |
Contact Lenses
(covered once per 24 months in lieu of complete pair of glassess) |
Covered up to $120 |
Covered up to $65 |
| Extra Discounts and Savings: |
Contacts: 15 percent off cost of contact lens exam (fitting and evaluation)
Laser Vision Correction: Average 15 percent off regular price or 5 percent off promotional price from contracted facilities.
|
| Out-of-plan Vision Services: You get the best value from your benefit when you see a VSP doctor. If you see a non-VSP provider, you’ll
typically pay more out-of-pocket. You will pay the provider in full and then have 6 months to submit a claim to VSP for partial reimbursement less copays. |
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