Page 30 - 2023-large-group-marketing-brochure

Copay Health Plans
Benefits per contract year
Hospital/other medical services
$806,7
Personal Choice PPO Keystone DPOS Keystone POS $50/$80/$500+$250 1
You pay in-network
$706,7
Personal Choice PPO Keystone DPOS Keystone POS $40/$70/$500 1
You pay in-network
Personal Choice PPO Keystone DPOS Keystone POS $30/$60/$400 1
You pay in-network
$0
$0
$0
0%
0%
0%
Preventive services4
$7,900/$15,800
$7,900/$15,800
$7,900/$15,800
$0
$0
$0
$0/$750
$0/$750
$0/$750
Physician services
$50/$35
$40/$30
$30/$20
$80/$55
$70/$50
$60/$40
$50
DPOS/POS — $405 PPO — Not covered
$40
$30
DPOS/POS — $405 PPO — Not covered
$0
DPOS/POS — $405 PPO — Not covered
$0
$0
$100
$806,7
$100
$100
$606,7
$706,7
$606,7
$500 per day for days 1-5, $250 per day for days 6-109/$0
$500 per day10/$0
$400 per day10/$0
$300
$300
$300
$300
$300
$300
$807
$300
$707
$300
$607
$200
$150/$300
$150/$300
$150/$300
$50/$100
$40/$80
$30/$60
50%
$80/$500 per day for days 1-5, $250 per day for days 6-109
50%
50%
$70/$500 per day10
$60/$400 per day10
$500
$400
$0 (POS/DPOS) $0/$160 (PPO)
$500
$0 (POS/DPOS) $0/$140 (PPO)
$0 (POS/DPOS) $0/$120 (PPO)
Prescription drugs
See prescription drug plans on page 48.
See prescription drug plans on page 48.
See prescription drug plans on page 48.
Out-of-network18,19
You pay out-of-network
You pay out-of-network
You pay out-of-network
$2,500/$5,000 (PPO/DPOS) $5,000/$10,000 (POS)
$2,500/$5,000 (PPO/DPOS) $5,000/$10,000 (POS)
$2,500/$5,000 (PPO/DPOS) $5,000/$10,000 (POS)
50% after ded
50% after ded
50% after ded
$10,000/$20,000 (PPO/DPOS) $30,000/$60,000 (POS)
$10,000/$20,000 (PPO/DPOS) $30,000/$60,000 (POS)
$10,000/$20,000 (PPO/DPOS) $30,000/$60,000 (POS)
Deductible — Individual/family
Coinsurance
Out-of-pocket maximum — Individual/family3
Preventive care for adults and children
Preventive colonoscopy for colorectal
cancer screening — Preventive Plus providers/ hospital-based22
Primary care visit — Office/virtual care Specialist visit — Office/virtual care Retail clinic
Eye exam
Virtual care23
Urgent care
Spinal manipulations (20 visits per year)
Physical/occupational therapy (30 visits per year) — Freestanding/hospital-based
Inpatient hospital services8/professional services (includes maternity)
Emergency room (not waived if admitted)11
Observation room (waived if admitted)
Routine radiology/diagnostic — Freestanding/hospital-based20
MRI/MRA, CT/CTA scan, PET scan — Freestanding/hospital-based
Biotech/specialty injectables — Home or office/outpatient
Infusion — Home or office/outpatient
Durable medical equipment/prosthetics
Mental health, serious mental illness, and substance abuse — Outpatient/inpatient8
Outpatient surgery —
Ambulatory surgical center/hospital-based
Outpatient lab/pathology — Freestanding/hospital-based
Low-cost generic drugs Generic drugs
Preferred brand drugs Non-preferred drugs Self-administered specialty drugs
Deductible
Coinsurance
Out-of-pocket maximum — Individual/family21
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