The coverage you need – with lower premiums
| Basic plan summary | |
|---|---|
| Plan type | PPO (Preferred Provider Organization) – Allows you to choose to receive care from network providers of your choice. |
| Deductible individual | No deductible |
| Deductible family | No deductible |
| Coinsurance | No coinsurance |
| Individual out-of-pocket | $5,000 |
| Family out-of-pocket | $10,000 |
| 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 | $30 copay |
| Office visit - specialist | $80 copay |
| 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 | $300 copay on the same day of service for one patient per one provider, then paid at 100% of maximum allowance |
| Outpatient Lab/X-ray | $30 copay per occurrence for each covered person |
| Outpatient surgery | $300 copay per occurrence, then paid at 100% of maximum allowance |
| Hospitalization | $1,500 per day copay up to a 3 day maximum per benefit period; then covered at 100% |
| 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 | $15 copay |
| Brand | $50 copay |
| Non-formulary | $75 copay |
| Specialty | $150 copay |
| Prescription drug – Mail order | |
| Generic | Not covered |
| Brand | Not covered |
| Non-formulary | Not covered |
| Specialty | Not covered |
| Maternity coverage | |
| Pre and postnatal office visit | Covered at 100% (spouses must be enrolled in same plan) |
| Labor and delivery hospital stay | $1,500 per day copay up to a 3 day maximum per benefit period; then covered at 100% (spouses must be enrolled in same plan) |
| Additional coverage | |
| Mental health | Provided at the same payment level that is applicable to the service provided for a condition other than mental health disorders. |
| Substance abuse | Provided at the same payment level that is applicable to the service provided for a condition other than substance abuse disorders. |
| Optional benefits | |
| Dental program | Dental coverage options |
| Hospital Indemnity Plan (HIP) | Cash benefits during hospitalization |
| Life insurance | Protection up to $50,000 |
| LTC Blue | Long-term care insurance |
| Plan 150 | Cancer policy |
Exclusions
See the Exclusions page for details.
Additional Program Information
More Information
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