Commonwealth Choice Silver Medium
*Please Note: This benefit plan is being discontinued. If you are a current member in the Silver Medium plan, you may be able to renew the plan through July 31, 2012. Please see the Enrollment Information for Individual Insurance Plan Members section of this EOC for more details regarding your options as a Silver Medium Plan member.
| Annual Out-of-Pocket Expenses per benefit year | Maximum amount |
|---|---|
| Per Person | $2,000 |
| Family total | $4,000 |
| Annual Deductible | Maximum amount |
| Per person | $500 |
| Family total | $1000 |
| Covered Benefit | Copayment |
| Outpatient Medical Care | |
| Community Health Center Visits (Primary Care and Specialist)
*No Copayment for adult routine physical, annual GYN exam well-child care, and early intervention services) |
$20/$20 |
| Office Visits (PCP/Specialists)
*No Copayment for adult routine physical, annual GYN exam and well-child care. |
$20/$20 |
| Outpatient Surgery (Hospital and Ambulatory Surgery Centers) | Deductible, then $0 |
| Diagnostic X-rays/Labs | Deductible, then $0 |
| Diagnostic CT/MRI/MRA/PET scan | Deductible, then $0 |
| Nuclear Cardiac Imaging | Deductible, then $0 |
| Inpatient Medical and Maternity Care | Deductible, then $0 |
| Prescription Drugs | |
| Medication via Pharmacy (1 month supply)
*Generics for treatment of high blood pressure, high cholesterol, and diabetes |
Generic* – $15
Preferred – $35 Non-preferred – $60 |
| Medication via Mail Order (90 day supply)
*Generics for treatment of high blood pressure, high cholesterol, and diabetes |
Generic* – $30
Preferred – $70 Non-preferred – $120 |
| Emergency Care (waived if admitted) | $100 |
| Mental Health (biological based) | |
| Office visits | $20 |
| Inpatient Admission | Deductible, then $0 |
| Mental Health (non-biological based) | |
| Office visits | $20 |
| Inpatient Admission | Deductible, then $0 |
| Substance Abuse | |
| Outpatient Office Visits and rehabilitation | $20 |
| Outpatient detoxification | $20 |
| Inpatient Admission (rehabilitation) | Deductible, then $0 |
| Inpatient Admission (detoxification) | Deductible, then $0 |
| Rehabilitation Services | |
| Cardiac Rehabilitation | Deductible, then $20 |
| Home Health Care | $0 |
| Inpatient Rehabilitation Services | |
| Skilled Nursing Facility (Up to 100 days per benefit year) | Deductible, then $0 |
| Inpatient Rehabilitation or Chronic Disease Hospital (Up to 60 days per benefit year) | Deductible, then $0 |
| 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) | Deductible, then $20 per visit |
| Autism Spectrum Disorder Services (no annual or lifetime benefit limits other than medical necessity) | |
| Outpatient Office Visits (Medical Necessity review after 12 visits) | $20 |
| Outpatient rehabilitation (Physical, Occupational and Speech Therapy, Social Work Visits) | Deductible, then $20 per visit |
| Habilitative Services (Professional, counseling and guidance services and treatment programs including but not limited to applied behavioral analysis) | Deductible, then $20 per visit |
| Other Benefits | |
| Ambulance (Emergency covered. Non-emergent covered only when prior authorized.) | Deductible, then $0 |
| Durable Medical Equipment, Supplies, Prosthetics, Orthotics, Oxygen, & Respiratory Therapy Equipment.
Combined limit of $1,000 per benefit year |
Deductible, then $0
$15 for Diabetic Supplies |
| Hospice | $0 |
| Routine foot care (for diabetics) | $0 |
| Vision (exam and glasses every 12 months) | $20 |
| Wellness (Family Planning, Nutritional Counseling, Prenatal, Nurse Midwife) | $0 |