Premier
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| Annual Out-of-Pocket Expenses per benefit year | Maximum amount | |
|---|---|---|
| Per person | Unlimited | |
| Family total | Unlimited | |
| Annual Deductible | Maximum amount | |
| Per person | None | |
| Family total | None | |
| Covered Benefit | Copayment | |
| Outpatient Medical Care | ||
| Community Health Center Visits (Primary Care/ Specialist) (No Copayment for adult routine physical, annual GYN exam, well-child care and early intervention services.) | $20/$30 | |
| Office Visits (PCP/Specialists) (No Copayment for adult routine physical, annual GYN exam, well-child care and early intervention services.) | $20/$30 | |
| Outpatient Surgery (Hospital and Ambulatory Surgery Centers) | $150 per surgery | |
| Diagnostic X-rays/Labs | $25/$25 | |
| Diagnostic CT/MRI/MRA/PET scan | $100/$100/$100/$100 | |
| Nuclear Cardiac Imaging | $100 | |
| Inpatient Medical and Maternity Care | $150 per admission | |
| Prescription Drugs | ||
| Medication via Pharmacy (1 month supply)
*Generics for treatment of high blood pressure, high cholesterol, and diabetes |
Generic* – $15
Preferred – $30 Non-preferred – $50 |
|
| Medication via Mail Order (90 day supply)
*Generics for treatment of high blood pressure, high cholesterol, and diabetes |
Generic* – $30
Preferred – $60 Non-preferred – $150 |
|
| Emergency Care (waived if admitted) | $75 | |
| Mental Health (biological based) | ||
| Office visits | $20 | |
| Inpatient Admission | $150 per admission | |
| Mental Health (non-biological based) | ||
| Office visits | $20 | |
| Inpatient Admission | $150 per admission | |
| Substance Abuse | ||
| Outpatient Office Visits and rehabilitation | $20 | |
| Outpatient detoxification | $20 | |
| Inpatient Admission (rehabilitation) | $150 per admission | |
| Inpatient Admission (detoxification) | $150 per admission | |
| Rehabilitation Services | ||
| Cardiac Rehabilitation | $25 | |
| Home Health Care | $0 | |
| Inpatient Rehabilitation Services | ||
| Skilled Nursing Facility (Up to 100 days per benefit year) | $150 per admission | |
| Inpatient Rehabilitation or Chronic Disease Hospital (Up to 60 days per benefit year) | $150 per admission | |
| Short-term outpatient rehabilitation (Physical and Occupational Therapies up to a combined limit of 60 days per benefit year)) | $25 per visit | |
| Speech Therapy (no limits other than medical necessity.) | $25 per visit | |
| Autism Spectrum Disorder Services (no annual or lifetime benefit limits other than medical necessity) | ||
| Outpatient Office Visits(Medical Necessity review after12 visits) | $20 | |
| Outpatient rehabilitation (Physical, Occupational and Speech Therapy, Social Work Visits) | $25 per visit | |
| Habilitative Services (Professional, counseling and guidance services and treatment programs including but not limited to applied behavioral analysis) | $25 per visit | |
| Other Benefits | ||
| Ambulance (Emergency covered. Non-emergent covered only when prior authorized.) | $0 | |
Durable Medical Equipment, Supplies, Prosthetics, Orthotics, Oxygen & Respiratory Therapy Equipment.
|
$0 | |
| Hospice | $0 | |
| Routine foot care (for diabetics) | $0 | |
| Vision (exam and glasses every 12 months) | $30 | |
| Wellness (Family Planning, Nutritional Counseling, Prenatal, Nurse Midwife) | $0 | |