Page 8 - 2019 Benefit Guide Non-CA
P. 8
HMO (OAP IN) MEDICAL COVERAGE
COVERAGE HMO (OAP IN)
Deductible $1,500 / $3,000
Maximum Out-of-Pocket (Single/Family) $4,500 / $9,000
Physician Services
PCP Office Visits $35 copay
Specialists Office Visits $55 copay
Lab, X-ray (Basic) 20% after deductible
Complex, Lab and X-ray 20% after deductible
Well Baby/Child Exam No copay
Adult Physicals No copay
Hospital Services
Room and Board 20% after deductible
Outpatient Surgery 20% after deductible
Emergency Care
Copayment (waived if admitted) $200 copay
Urgent Care $35 copay
Ambulance - Emergency Only No copay
Durable Medical Equipment 20% after deductible
Prescription Drugs
Tier 1 - Generic Formulary $15 copay
Tier 2 - Brand Name Formulary $30 copay
Tier 3 - Non Formulary $45 copay
Tier 4 - Specialty/Injectable $100 copay
2x copay
Mail Order: Up to 90-day supply
Tier 1, 2 and 3
8
