Page 31 - 2023-large-group-marketing-brochure

Copay Health Plans
Benefits per contract year
You pay in-network
Personal Choice PPO Keystone DPOS Keystone POS $20/$40/$250 1
You pay in-network
Personal Choice PPO $15/$35/$150 1
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
$0
0% $7,900/$15,800
$0 $0/$750
$15/$10 $35/$25 $15
Not covered
$0 $70 $356
$356
$150 per day10/$0
$200 $200
$35 $70
$100/$200
$15/$30 50%
$35/$150 per day10 $150
$0/$70
See prescription drug plans on page 48.
You pay out-of-network
$2,500/$5,000 50% after ded $10,000/$20,000
$0
0%
$7,900/$15,800
Preventive services4
$0
$0/$750
Physician services
$20/$15
$40/$30
$20
DPOS/POS — $355 PPO — Not covered
$0
$85
$406,7
$406,7
Hospital/other medical services
$250 per day10/$0
$250
$250
$407
$80
$100/$200
$20/$40
50%
$40/$250 per day10
Prescription drugs
$250
$0 (POS/DPOS) $0/$80 (PPO)
See prescription drug plans on page 48.
Out-of-network18,19
You pay out-of-network
$2,500/$5,000 (PPO/DPOS) $5,000/$10,000 (POS)
50% after ded
$10,000/$20,000 (PPO/DPOS) $30,000/$60,000 (POS)
Footnotes begin on page 58 | ded = Deductible
2023 Large Group Plans | Independence Blue Cross 30