Covered Benefit

Member Share

Plan Year Deductible

$0

Out-of-Pocket-Maximum (In-Network)

$2,500

Out-of-Pocket Maximum (Out-of-Network)

There is no out-of-network maximum. Out-of-network services do not count towards the in-network maximum.

Co-pay – Primary Care/Specialist

$0 copay per visit with network primary care providers; $10 copay per visit with network specialists; referrals are required for in-network specialist physician services, occupational therapy, physical therapy, speech-language pathology and other health care professional visits

Out-of-network: 20% coinsurance per visit

Emergency Room

$50 co-pay per visit

Inpatient Hospital

$50/day (days 1-10 with network providers)

Out-of-network: Medicare-defined cost sharing, $1,736 deductible for days 1 to 60, $434 copay each day for days 61 to 90 and $868 copay each day for days 91 to 150 (lifetime reserve day)

Prescription Drugs (Part D)

•  Tier 1
•  Tier 2
•  Tier 3
•  Tier 4
•  Tier 5

•  $0
•  $0
•  $20 (30 day supply)
•  $40 (30 day supply)
•  20%

Additional Benefits

Preventative Dental

$0 copay for oral exams, cleanings and X-rays from network providers; coverage frequency varies. Out-of-network services may have higher costs.

Comprehensive Dental

$0 copay – 50% coinsurance for comprehensive services from network providers; coverage frequency varies. Covered up to $2,000 per year for comprehensive and preventive services. Out-of-network services may have higher costs.

Diagnostic Hearing Exam

$10 copay for each diagnostic hearing exam and $0 copay for each routine hearing exam from network providers; 20% coinsurance for diagnostic hearing exams from out-of-network providers.

Meal Benefit

$0 copay for home-delivered meals from the network meal provider after an eligible hospital stay. Restrictions apply.

Respite Care

$0 copay for each session with the network respite care provider, up to 12 sessions every year. This benefit is for members diagnosed with dementia. Restrictions apply.

Eyewear

$0 copay for one pair of standard lenses for routine vision correction each year from network providers; plan pays up to $200 every year for frames or contact lenses from network providers.