Plan Features |
| |
In-Network |
Out-of-Network1 |
| Annual Deductible per Enrollee |
$500 |
$1,000 |
| Out-of-Pocket Maximum2 (Annual amount enrollees pay excluding the annual deductible and prescription drug copayments) |
$800 per single enrollee
$1,200 per family |
$3,000 per single enrollee
$6,000 per family |
| Lifetime Benefits Maximum per Enrollee |
$2,000,000 |
$1,000,000 |
| Health Provider Access |
Use network provider |
Use any provider |
Physician, Hospital, Skilled Nursing & Home Health Care |
| Physician Office Visit |
Enrollee pays 20% |
Enrollee pays 50% |
| Hospital Inpatient Services |
| Hospital Charges for Outpatient Surgery and Preadmission Testing |
| Emergency Room Care |
Enrollee pays 20% (no deductible) |
Enrollee pays 20% (no deductible) |
Skilled Nursing Facility |
Enrollee pays 20% (90 days per benefit period); after 90 days, enrollee pays 100% |
Enrollee pays 50% (90 days per benefit period); after 90 days, enrollee pays 100% |
| Inpatient Mental Health |
Enrollee pays 20%; no limit on days |
Enrollee pays 50%; no limit on days |
| Home Health Care |
Enrollee pays 20%; 100-visit limit per calendar year |
Enrollee pays 50%; 100-visit limit per calendar year |
Preventive Services |
Physical Exam |
Enrollee pays $15
(no deductible); $200 limit per calendar year; bone density screening limit one per calendar year |
Enrollee pays 50%
(no deductible);
$200 limit per
calendar year; bone density screening limit one per calendar year |
| Bone Density Screening |
| Immunizations/Inoculations |
Enrollee pays 20% |
Enrollee pays 50% |
| Colorectal Cancer Screening |
Limited coverage |
| Prostatic Specific Antigen (PSA) |
Enrollee pays 20%
(no deductible);
limit one per calendar year
|
Enrollee pays 50%
(no deductible);
limit one per calendar year
|
| Pap Smear |
| Mammogram |
Enrollee pays 20% (no deductible); limit one per calendar year |
Enrollee pays 50% (no deductible); limit one per calendar year |
Outpatient Services |
| Diagnostic X-ray and Lab Testing |
Enrollee pays 20% |
Enrollee pays 50% |
| Outpatient Mental Health |
Enrollee pays 20%; 30-visit limit per calendar year |
Enrollee pays 50%; 30-visit limit per calendar year |
Additional Services |
| Dental Care |
No coverage |
No coverage |
| Vision Care |
Prescription Drug Coverage |
| Retail Network Provider |
AultCare Prescription Program |
Retail Copayment/
Coinsurance3 |
Generic: $10 or 20%, whichever is greater
Formulary brand-name: $15 or 25%, whichever is greater
Nonformulary brand-name: $30 or 30%, whichever is greater
Out-of-network pharmacy: Reimbursed the amount AultCare would have been charged at a network pharmacy, less copayment |
| Maximum Day Supply at Retail4 |
34 |
| Mail-Order Provider |
BioScrip |
| Mail-Order Copayment3 |
Generic: $20
Formulary brand-name: $30
Nonformulary brand-name: $45 |
| Maximum Day Supply at Mail Service4 |
60 |