Page 34 - 2022 Large Group benefits

Copay Health Plans
Benefits per contract year
Hospital/other medical services
$806 7
Personal Choice PPO Keystone Keystone DPOS Keystone Keystone POS POS $50/$80/$500+$250 1
You pay in-network
Personal Choice PPO Keystone Keystone DPOS Keystone Keystone POS POS $40/$70/$500 1
You pay in-network
Personal Choice PPO Keystone Keystone DPOS Keystone Keystone POS 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
$100
$100
$706 7
7
$606 7
$806 7
$706 7
7
$606 7
$500 per per day day day day for for days days 1-5 $250 per per day day day day for for days 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 per day day day day for for days days 1-5 $250 per per day day day day for for days days 6-109 50%
50%
$70/$500 per day10 $60/$400 per day10 $500 $400 $0
$0
(POS/DPOS) $0/$160 (PPO)
$500 $0
$0
(POS/DPOS) $0/$140 (PPO)
$0
$0
(POS/DPOS) $0/$120 (PPO)
Prescription drugs
See prescription drug plans on on page 57
See prescription drug plans on on page 57
See prescription drug plans on on page 57
Out-of-network18 19
You pay out-of-network
You pay out-of-network
You pay out-of-network
$2 500/$5 000 000 000 (PPO/DPOS) $5 $5 000/$10 000 000 000 (POS)
$2 500/$5 000 000 000 (PPO/DPOS) $5 $5 000/$10 000 000 000 (POS)
$2 500/$5 000 000 000 (PPO/DPOS) $5 $5 000/$10 000 000 000 (POS)
50%
after ded
50%
after ded
50%
after ded
$10 000/$20 000 000 000 000 (PPO/DPOS) $30 000/$60 000 000 000 000 (POS)
$10 000/$20 000 000 000 000 (PPO/DPOS) $30 000/$60 000 000 000 000 (POS)
$10 000/$20 000 000 000 000 (PPO/DPOS) $30 000/$60 000 000 000 000 (POS)
Deductible — individual/family
Coinsurance
Out-of-pocket maximum — individual/family3
Preventive care for adults and children
Preventive 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 Care (from designated virtual provider)23
Urgent care Spinal manipulations (20 visits per year)
Physical/occupational therapy (30 visits per year)
Freestanding/Hospital-based
Inpatient hospital services8/professional services
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 scan PET scan 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
33