| |
Benefits
PCY=Per Calendar Year
|
BALANCE 1750 |
BALANCE 2500 |
BALANCE 5000 |
|
Annual
Deductible |
Individual: $1,750
Family: $5,250 |
Individual: $2,500
Family: $7,500 |
Individual: $5,000
Family: $15,000 |
|
Member
Coinsurance |
20% (in-network)
40%
(out-of-network) |
40%
(in-network)
40% (out-of-network) |
50%
(in-network)
50% (out-of-network) |
| |
Out-Of-Pocket Limit (Deductible does not
apply) |
Individual: $6,000
Family: $18,000 |
Individual: $8,000
Family: $24,000 |
Individual: $10,000
Family: $30,000 |
| |
BENEFITS (DEDUCTIBLE
DOES NOT APPLY) |
| |
Preventive Care
For children and
adults, including physicals and immunizations, as established in Group
Health's preventive care schedule. Out of
network: $30/visit + Coinsurance with annual benefit
maximum of $300 individual/$600 family |
Deductible Waived;
Covered in full
(in-network) |
Deductible Waived;
Covered in full (in-network) |
Deductible Waived;
Covered in full (in-network) |
| |
Prescription Drugs
Outpatient: Drugs and medicines
that require prescription, including self-administered injectables, contraceptive drugs,
devices, and supplies. |
In-network:
$15 generic/40% brand name/50% non-formulary
Mail Order:
$5 discount for 30-day supply
Out-of-network: $20 generic/40%
brand name/50% non-formulary
|
Not Covered |
Not
Covered |
| |
Vision Care
$200 hardware benefit per 12 months. Not
subject to coinsurance or deductible. |
In-network:
$30 for routine eye exam per 12 months
Out-of-network: covered up to $30
for routine eye exam per 12 months.
|
In-network:
$30 for routine eye exam per 12 months
Out-of-network: covered up to $30
for routine eye exam per 12 months.
*Hardware not covered
|
In-network:
$30 for routine eye exam per 12 months
Out-of-network: covered up to $30
for routine eye exam per 12 months.
*Hardware not covered
|
| |
BENEFITS
(Alliant Plus in-network:
no deductible;
out-of-network:
Copay + COINSURANCE after deductible) |
|
Office
Visits
Including mental health outpatient services. |
In-network: $30/visit copay
Specialty care: $50/visit copay
|
In-network: $30/visit copay
Specialty care: $50/visit copay
|
In-network: $30/visit copay
Specialty care: $50/visit copay
|
| |
Manipulative Therapy
Limit total visits PCY to 10 combined for both in-
and out-of-network. |
$30/visit copay |
$30/visit copay |
$30/visit
copay |
| |
Acupuncture
In-network: up to 8
visits PCY |
$30/visit copay |
$30/visit copay |
$30/visit
copay |
| |
Naturopathy
In-network: up to 3
visits PCY |
$30/visit copay |
$30/visit copay |
$30/visit
copay |
| |
Maternity Care (outpatient non-routine prenatal &
postpartum visits. Copay waived for routine care.) |
$30/visit copay |
Not Covered |
Not
Covered |
| |
BENEFITS (AFTER
DEDUCTIBLE, MEMBER PAYS) |
| |
Hospital
Visits - Inpatient
Hospital room and
board; inpatient surgery; anesthesia, intensive and coronary care,
laboratory tests, radiology services, drugs while in hospital. Includes
mental health inpatient treatment. |
$300 per day up to 5 days/admit
+ 20% |
$100 per day up to 5
days/admit
+ 40% |
$100
per day up to 5 days/admit +50% |
| |
Lab/X-Ray Services
(Out of network: Deductible & Coinsurance) |
Deductible
Waived on first $400 PCY, then deductible and 20% apply. |
Deductible
Waived on first $200 PCY, then deductible and 40% apply. |
Deductible Waived on first $200 PCY, then deductible
and 50% apply. |
| |
Devices, Equipment & Supplies (DME
and Prosthetics) |
50% |
50% |
50% |
| |
Emergency Care |
$100 copay
then
subject to deductible, then 20%.
|
$100
copay
then subject
to deductible, then 40%.
|
$100 copay
then subject
to deductible, then 50%.
|
