Page 35 - 2022 Large Group benefits

Copay Health Plans
Benefits per contract year
You pay in-network
Personal Choice PPO Keystone Keystone DPOS Keystone Keystone POS POS $20/$40/$250 1
You pay in-network
Personal Choice PPO $15/$35/$150 1
1
1
Deductible — individual/family
Coinsurance
Out-of-pocket maximum — individual/family3
Preventive services4
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
$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 on page 57
You pay out-of-network
$2 500/$5 000 50%
after ded
$10 000/$20 000 000 $0
0%
$7 900/$15 800
$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
$0
(POS/DPOS) $0/$80 (PPO)
See prescription drug plans on on page 57
Out-of-network18 19
You pay out-of-network
$2 500/$5 000 000 000 (PPO/DPOS) $5 $5 000/$10 000 000 000 (POS)
50%
after ded
$10 000/$20 000 000 000 000 (PPO/DPOS) $30 000/$60 000 000 000 000 (POS)
2022 Large Group Plans
| Independence Blue Cross 34