| Features/Benefits |
Specifics |
| Plan Type |
HMO |
| Annual Deductibles |
$250 (individual) |
|
$500 (family) |
| Out-of-Pocket Maximum |
$5,000 (individual) |
|
$10,000 (family) |
| Office Visits |
|
| Well-child Care Visit |
$0 |
| Routine Adult Physical |
$0 |
| Routine GYN Exam |
$0 |
| Routine Vision Exam (one per 12 months) |
$15 |
| Emergency Room Visit |
$150 (waived if admitted) |
| Most Other Office Visits |
$25 (Primary Care Provider) |
|
$40 (Specialist) |
| Prescription Drugs |
|
| Retail |
Tier 1: $15 |
|
Tiers 2 and 3: 50% coinsurance after Prescription Drug |
|
deductible of $250 (individual) or $500 (family) |
| Mail Order |
Tier 1: $30 |
|
Tiers 2 and 3: 50% coinsurance after Prescription Drug |
|
deductible of $250 (individual) or $500 (family) |
| X-rays, Labs, and Diagnostic Tests |
35% coinsurance after deductible |
| Inpatient Care (including Maternity Care) |
|
| Semi-private room and board |
35% coinsurance after deductible |
| Outpatient Surgery |
35% coinsurance after deductible |
| Mental Health and Substance Abuse |
|
| Outpatient office visits |
$25 |
| Inpatient Admission |
35% coinsurance after deductible |
| Ambulance |
35% coinsurance after deductible |
| Value-Added Benefits |
|
| CentAccount Healthy Rewards Program |
Get rewarded for completing designated healthy behaviors, |
|
starting with your first PCP visit within 90 days of enrollment |
| Nursewise |
A free health information phone line staffed with registered nurses |
|
ready to answer your health questions 24-hours a day – every day of the year |
| Balance |
Free health and wellness program offering resources to help you |
|
remove life barriers and focus on a healthier you |