Page 44 - 2023-large-group-marketing-brochure

Choice Advantage Health Plans
Benefits per contract year
You pay in-network
Keystone POS CA $40/$85/$500 1
You pay in-network
Personal Choice PPO CA $40/$85/$500 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
$40/$30 $85/$60 $40
Not covered $0
$100 $856
$50/$1506
$500 per day10/$0
$300 $300
$50/$150
$200/$400
$150/$300
$40/$80 50%
$85/$500 per day10 $350/$700 $0/$170
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
$40/$30
$85/$60
$40
$405
$0
$100
$857
$857
Hospital/other medical services
$500 per day10/$0
$300
$300
$857
$300
$150/$300
$40/$80
50%
$85/$500 per day10
$350/$700
$0
Prescription drugs
See prescription drug plans on page 48.
Out-of-network18,19
You pay out-of-network
$5,000/$10,000
50% after ded
$30,000/$60,000
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