Page 68 - 2023-small-group-brochure

22 K e K y e s y t s o t n o e n He MD OP O B S r o B n r z o e n z E e s s E e s n s t e i n a t l i a l
$7$,570,500/0$/7$07/0$/1$4104/0$/7$07000
Youpaayyinin--nettworrkk6 You pay out-of-network5
Bronze health plans
Benefits per contract year1
Preventive services8
Physician services
67
Deductible, individual/family
Coinsurance
Out-of-pocket maximum, individual/family includes:
Preventive care for adults and children
Preventive colonoscopy for colorectal cancer screening — Preventive Plus providers Preventive colonoscopy for colorectal cancer screening — hospital-based
Primary care visit — office/virtual care Specialist visit — office/virtual care
Retail clinic
Virtual care (from designated virtual provider)† Urgent care
Spinal manipulations (20 visits per year)/Acupuncture§ (18 visits per year) Physical/Occupational therapy — (30 visits per year) — freestanding/hospital-based
Inpatient hospital services (includes maternity)
Inpatient professional services (includes maternity) Emergency room
Routine radiology — freestanding/hospital-based
MRI/MRA, CT/CTA/PET scan — freestanding/hospital-based Biotech/Specialty injectables — home, office/outpatient Infusion — home, office/outpatient
Durable medical equipment/Prosthetics
Outpatient mental health and substance abuse — office visit/all other Inpatient mental health and substance abuse
Outpatient surgery — ambulatory surgical facility/hospital-based Outpatient lab/Pathology — freestanding/hospital-based
Rx deductible (individual/family) Low cost generic18
Retail generic18
Retail preferred brand18,21 Retail non-preferred drug18,21 Specialty drug21
Pediatric routine eye exam24, 25 and eyewear (glasses or contacts)24, 26 Adult routine eye exam25
Adult eyewear (glasses or contacts)27
Pediatric dental deductible (per individual)29 Pediatric exams and cleanings29, 30
Pediatric basic, major, and orthodontia services29, 31
Hospital/other medical services
$$77,5,5000/$/$1155,0,000
5500%
$$89,,51500//$178,1,2000ccooininssuurraannccee, ,ccooppaayyss, ,aannddddeedd
00% % n no o d de ed d 00%nnooddeedd $$775500 n no o d de ed d
$$7700 n no o d de ed d / $ 5 0 n o d e d $$114400 n no o d de ed d / $ 9 5 n o d e d
$70 no ded
00% % n no o d de ed d
$$115500 a af ft te er r d de ed d 10
$10,000/$20,000
50%
$40,000/$80,000 coinsurance and ded
50% no ded N/A
50% no ded
50% after ded 50% after ded
Not covered
50% after ded
50% after ded
50% after ded /50% after ded
50% after ded
50% after ded
$500 after in-network ded 50% after ded /50% after ded 50% after ded /50% after ded 50% after ded /50% after ded 50% after ded /50% after ded 50% after ded
50% after ded
50% after ded
50% after ded /50% after ded
Integrated
70% of retail, no ded 70% of retail after ded 7 0 % o f r e t a i l a f t e r d e d 7 0 % o f r e t a i l a f t e r d e d Not covered
Not covered Not covered Not covered
Not covered Not covered Not covered
You pay in-
$7,000/$14,00
0%
$7,000/$14,00 coinsurance, co
0% no ded 0% no ded $750 no ded
0% after ded 0% after ded 0% no ded
0% after ded 0% after ded9 0% after ded/0
0% after ded 0% after ded 0% after ded 0% after ded/0 0% after ded/0 0% after ded/0 0% after ded/0 0% after ded 0% after ded 0% after ded 0% after ded/0 0% after ded/0
Integrated
0% after ded20 0% after ded20 0% after ded20 0% after ded20 0% after ded20
$0 no ded
$0 no ded
Allowance up t contact lenses; allowance at Vi
Integrated 0% no ded 0% after ded
$$114400 n no o d de ed d
$ $ 1 1 4 4 0 0 n n o o d d e e d d / $/ $ 1 1 4 4 0 0 n n o o d d e e d d
10
111 S S u u b b j ej e c c t t t t o o d d e e d d a a n n d d $ $ 7 7 0 0 0 0 p p e e r r d d a a y y
5500% % a af ft te er r d de ed d
$$5500 00 a af ft te er r d de ed d ( w a i v e d i f a d m i t t e d )
10 $ $ 1 1 5 5 0 0 n n o o d d e e d d / $/ $ 1 1 5 5 0 0 n n o o d d e e d d
$ $ 3 3 5 5 0 0 n n o o d d e e d d / $/ $ 3 3 5 5 0 0 n n o o d d e e d d
$ $ 1 1 0 0 0 0 n n o o d d e e d d / $/ $ 1 1 0 0 0 0 n n o o d d e e d d
5 $ 0 1 %4 0 a f a t f e t r e r d e d d e / d 5 / $0 2% 8 a 0 f a t e f r t e d r e d d e d 5500% % a af ft te er r d de ed d
$$114400 n no o d de ed d / $ 1 4 0 n o d e d
S S u u b b j ej e c c t t t t o o d d e e d d a a n n d d $ $ 7 7 0 0 0 0 p p e e r r d d a a y y
111 $1,000 after ded/$1,000 after ded
0 0 % % n n o o d d e e d d / 0/ 0 % % n n o o d d e e d d IInntteeggrraatteedd
20 $$35 n no o d de ed d
20 $$2205 a af ft te er r d de ed d
20, 21 5 50 0% % a af ft te er r d de ed d u up p t to o $ $5 50 0 0 0 m ma ax x p pe er r f fi l i l l l
20, 21 5 50 0% % a af ft te er r d de ed d u up p t to o $ $5 50 0 0 0 m ma ax x p pe er r f fi l i l l l
20, 21 5500% % a af ft te er r d de ed d
$$00 n no o d de ed d
$$00 n no o d de ed d
A A l l l ol o w w a a n n c c e e u u p p t t o o $ $ 1 1 3 3 0 0 f f o o r r f f r r a a m m e e s s o o r r c c o o n n t t a a c c t t l e l e n n s s e e s s ; ; u u p p t t o o $ $ 1 1 8 8 0 0 f f r r a a m m e e a a l l l ol o w w a a n n c c e e a a t t V V i s i s i oi o n n w w o o r r k k s s s s t t o o r r e e s s
$$00
$$00 CCooppaayyvvaarrieiess
21 21
Prescription drugs16, 17, 19, 20
Vision and dental23, 28, 32
Preferred: Copay plans | Classic: Coinsurance/deductible plans | Secure: Copay/deductible plans
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