Commonwealth Choice Silver High
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| Annual Out-of-Pocket Expenses per benefit year | Maximum amount |
|---|---|
| Per Person | $2,000 |
| Family total | $4,000 |
| 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.) | $25/$25 |
| Office Visits (PCP/Specialists)
*No Copayment for adult routine physical, annual GYN exam, well-child care, and early intervention services.) |
$25/$25 |
| Outpatient Surgery (Hospital and Ambulatory Surgery Centers) | $500 per surgery |
| Diagnostic X-rays/Labs | $0/$0 |
| Diagnostic CT/MRI/MRA/PET scan | $75/$75/$75/$75 |
| Nuclear Cardiac Imaging | $75 |
| Inpatient Medical and Maternity Care | $500 per admission |
| Prescription Drugs | |
| Medication via Pharmacy (1 month supply)
*Generics for treatment of high blood pressure, high cholesterol, and diabetes |
Generic* – $15
Preferred – 50% coinsurance Non-preferred – 50% coinsurance |
| Medication via Mail Order (90 day supply)
*Generics for treatment of high blood pressure, high cholesterol, and diabetes |
Generic* – $30
Preferred – 50% coinsurance Non-preferred – 50% coinsurance |
| Emergency Care (waived if admitted) | $100 |
| Mental Health (biological based) | |
| Office visits | $25 |
| Inpatient Admission | $500 per admission |
| Mental Health (non-biological based) | |
| Office visits | $25 |
| Inpatient Admission | $500 per admission |
| Substance Abuse | |
| Outpatient Office Visits and rehabilitation | $25 |
| Outpatient detoxification | $25 |
| Inpatient Admission (rehabilitation) | $500 per admission |
| Inpatient Admission (detoxification) | $500 per admission |
| Rehabilitation Services | |
| Cardiac Rehabilitation | $25 |
| Home Health Care | $0 |
| Inpatient Rehabilitation Services | |
| Skilled Nursing Facility (Up to 100 days per benefit year) | $500 per admission |
| Inpatient Rehabilitation or Chronic Disease Hospital (Up to 60 days per benefit year) | $500 per admission |
| Short-term outpatient rehabilitation (Physical and Occupational Therapy limited to a combined 60 visits per benefit year; Speech Therapy no limits other than medical necessity) | $25 |
| Autism Spectrum Disorder Services (no annual or lifetime benefit limits other than medical necessity) | |
| Outpatient Office Visits (Medical Necessity review after 12 visits) | $25 |
| 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) | $25 |
| Wellness (Family Planning, Nutritional Counseling, Prenatal, Nurse Midwife) | $0 |