Page 37 - 2022 Large Group benefits

Deductible/Copay Health Plans
Benefits per contract year
Physician services Personal Choice PPO Keystone Keystone DPOS Keystone Keystone POS POS $3 $3 000/$30/$60/90% 1 You pay in-network
$0/$750 no ded $60 no ded6 7 10% 10% after after ded/10% after after ded ded 0% no ded Personal Choice PPO Keystone Keystone DPOS Keystone Keystone POS POS $4 000/$30/$60/90% 1 You pay in-network
$60 no ded6 7 10% 10% after after ded/10% after after ded ded $60 no ded7 Personal Choice PPO Keystone Keystone DPOS Keystone Keystone POS POS $5 000/$30/$60/90% 1 You pay in-network
$3 000/$6 000 000 $4 000/$8 000 000 $5 000/$10 000 000 10% 10% 10% $7 900/$15 800
$7 900/$15 800
$7 900/$15 800
0% no ded 0% no ded $0/$750 no ded $30 no no ded/$20 no no ded ded $0/$750 no ded $30 no no ded/$20 no no ded ded $30 no no ded/$20 no no ded ded $60 no no ded/$40 no no ded ded $60 no no ded/$40 no no ded ded $60 no no ded/$40 no no ded ded $30 no ded DPOS/POS — — $40 no ded5 PPO — — Not covered"
$30 no ded $30 no ded DPOS/POS — — $40 no ded5 PPO — — Not covered
DPOS/POS — — $40 no ded5 PPO — — Not covered
$0 no ded $0 no ded $0 no ded $100 no ded $100 no ded $100 no ded $60 no ded6 7 $60 no ded6 7 $60 no ded6 7 $60 no ded6 7 Hospital/other medical services 10% 10% after after ded/10% after after ded ded $300 after ded $300 after ded $300 after ded 10% after ded 10% after ded $60 no ded7 10% after ded $60 no ded7 $200 no ded $200 no ded $200 no ded $150 no no ded/$300 no no ded ded $150 no no ded/$300 no no ded ded $150 no no ded/$300 no no ded ded 10% after after ded/30% after after ded ded 10% after after ded/30% after after ded ded 10% after after ded/30% after after ded ded 10% after ded 10% after ded $60 no ded/10% after ded ded 10% after ded $60 no ded/10% after ded ded $60 no ded/10% after ded ded 10% after ded 10% after ded 10% 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)
$60 $60 no no no ded ded ded (POS/DPOS)
$60 $60 no no no ded/$120 no no no ded ded ded (PPO)
$60 $60 no no no ded ded ded (POS/DPOS)
$60 $60 no no no ded/$120 no no no ded ded ded (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
$5 000/$10 000 000 $6 000/$12 000 000 $7 500/$15 000 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)
$12 000/$24 000 000 000 000 (PPO/DPOS) $30 000/$60 000 000 000 000 (POS)
$15 000/$30 000 000 000 000 (PPO/DPOS) $30 $30 000/$60 000 000 000 000 (POS)
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
2022 Large Group Plans
| Independence Blue Cross 36