Affordable protection for hospital services.
| Basic plan summary | |
|---|---|
| Plan type | PPO (Preferred Provider Organization) – Allows you to choose to receive care from network providers of your choice. |
| Deductible individual | $500 / $1,000 |
| Deductible family | $1,000 / $2,000 |
| Coinsurance | 50% |
| Individual out-of-pocket maximum after deductible | $1,000 |
| Family out-of-pocket maximum after deductible | $2,000 |
| Individual lifetime maximum | Unlimited |
| Dependent coverage | Eligible children covered to age 26 |
| HSA eligibility | No |
| Doctor office visits (illness and injury) | |
| Office visit - history and exam | Not covered |
| Office visit - specialist | Not covered |
| How can I find a doctor in this plan's Network? | Search for a doctor or hospital here |
| Do I need permission from my primary care doctor to see a specialist? | No |
| Do I need authorization before seeing an out-of-network doctor? | No |
| Hospital services | Your cost sharing |
| Emergency room | Non-accident or medical emergency; the initial treatment is subject to 50% coinsurance after deductible |
| Accident coverage | Initial treatment is subject to 50% coinsurance after deductible; three outpatient follow-up office visits covered within 60 days of initial treatment. If admitted during initial treatment, three follow-up visits are not included. |
| Outpatient Lab/X-ray | 50% coinsurance after deductible |
| Outpatient surgery | 50% coinsurance after deductible |
| Hospitalization | 50% coinsurance after deductible |
| Preventive care | |
| As part of the Affordable Care Act, preventive services are paid at 100% of the allowable charge for new enrollees after Sept. 23, 2010. This includes routine screenings, immunizations, checkups and counseling received to prevent illness or disease. Learn more. | |
| Periodic health exam | No charge |
| Periodic OB-GYN exam | No charge |
| Well baby care | No charge |
| Prescription drug | |
| Generic | Not covered |
| Brand | Not covered |
| Non-formulary | Not covered |
| Prescription drug – Mail order | |
| Generic | Not covered |
| Brand | Not covered |
| Non-formulary | Not covered |
| Maternity coverage | |
| Pre and postnatal office visit | Not covered |
| Labor and delivery hospital stay | 50% coinsurance after deductible (spouses must be enrolled in same plan) |
| Additional coverage | |
| Mental health | Subject to deductible and coinsurance |
| Substance abuse | Subject to deductible and coinsurance |
| Optional benefits | |
| Dental program | Dental coverage options |
| Hospital Indemnity Plan (HIP) | Cash benefits during hospitalization |
| Life insurance | Life coverage options |
| LTC Blue | Long-term care insurance |
| Plan 150 | Cancer policy |
Exclusions
See the Exclusions page for details.
Additional Program Information
More Information