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. There are also several preventive services for women paid at 100% of the allowable charge for new enrollees on or after Aug. 1, 2012. For a complete listing, please click here. | |
| 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 |
| 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