Page 36 - 2022 Large Group benefits

Benefits per contract year
You pay in-network
You pay in-network
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
$2 000/$4 000 000 20% $7 900/$15 800
0% no ded $0/$750 no ded $30 no no ded/$20 no no ded ded $60 no no ded/$40 no no ded ded $30 no ded DPOS/POS — — $40 no ded5 PPO — — Not covered
$0 no ded $100 no ded $60 no ded6 7 $60 no ded6 7 20% 20% after after ded/20% after after ded ded $300 after ded 20% after ded $60 no ded7 $200 no ded $150 no no ded/$300 no no ded ded 20% after after ded/40% after after ded ded 20% after ded $60 no ded/20% after ded ded 20% after ded $60 $60 no no no ded ded ded (POS/DPOS)
$60 $60 no no no ded/$120 no no no ded ded ded (PPO)
See prescription drug plans on on page 57
You pay out-of-network
$5 000/$10 000 000 50% after ded $10 000/$20 000 000 000 000 (PPO/DPOS) $30 000/$60 000 000 000 000 (POS)
$3 500/$7 000 30%
$7 900/$15 800
Preventive services4
0% no ded $0/$750 no ded Physician services $20 no no ded/$15 no no ded ded $40 no no ded/$30 no no ded ded $20 no ded $35 no ded5 $0 no ded $85 no ded $40 no ded7 $40 no ded7 Hospital/other medical services 30%
30%
after after ded/30% after after ded ded $250 after ded 30%
after ded $40 no ded7 $80 no ded $100 no no ded/$200 no no ded ded 30%
after after ded/50% after after ded ded 30%
after ded $40 no ded/30% after ded ded Prescription drugs 30%
after ded $40 no ded See prescription drug plans on on page 57
Out-of-network18 19
You pay out-of-network
$5 000/$10 000 000 50% after ded $30 000/$60 000 000 35 Deductible/Copay Health Plans
Keystone POS $3 500/$20/$40/70% 1 Personal Choice PPO Keystone Keystone DPOS Keystone Keystone POS POS $2 000/$30/$60/80% 1