Page 39 - 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/$60/100% 1 1 You pay in-network
$0/$750 no ded Personal Choice PPO Keystone Keystone DPOS Keystone Keystone POS POS $5 000/$40/$70/100%1
You pay in-network
0% no ded Personal Choice PPO $6 000/$20/$40/100% 1 1 You pay in-network
$3 000/$6 000 000 $5 000/$10 000 000 $6 000/$12 000 000 0% 0% 0% $7 900/$15 800
$7 900/$15 800
$7 900/$15 800
0% no ded 0% no ded $0/$750 no ded $40 no no ded/$30 no no ded ded $0/$750 no ded $30 no no ded/$20 no no ded ded $20 no no ded/$15 no no ded ded $60 no no ded/$40 no no ded ded $70 no no ded/$50 no no ded ded $40 no no ded/$30 no no ded ded $30 no ded DPOS/POS — — $40 no ded5 PPO — — Not covered
$40 no ded $20 no ded DPOS/POS — — $40 no ded5 PPO — — Not covered
Not covered
$0 no ded $0 no ded $0 no ded $100 no ded $100 no ded $85 no ded $60 no ded6 7 $70 no ded6 7 7 $40 no ded6 $60 no ded6 7 $60 no ded7 $70 no ded6 7 7 $70 no ded7 $40 no ded6 Hospital/other medical services 0% 0% after after ded/0% after after ded ded 0% 0% after after ded/0% after after ded ded 0% 0% after after ded/0% after after ded ded $300 after ded $300 after ded $250 after ded $300 after ded $300 after ded $250 after ded $40 no ded $200 no ded $300 no ded $150 no no ded/$300 no no ded ded $80 no ded $150 no no ded/$300 no no ded ded $100 no no ded/$200 no no ded ded 0% 0% after after ded/20% after after ded ded 0% 0% after after ded/20% after after ded ded 0% 0% after after ded/20% after after ded ded 0% after ded $60 no ded/0% after ded ded 0% after ded 0% after ded $70 no ded/0% after ded ded $40 no ded/0% after ded ded 0% after ded 0% after ded Prescription drugs $60 $60 no no no ded ded ded (POS/DPOS)
$60 $60 no no no ded/$120 no no no ded ded ded (PPO)
0% after ded $70 $70 no no no ded ded ded (POS/DPOS)
$70 $70 no no no ded/$140 no no no ded ded ded (PPO)
$40 $40 no no no ded ded ded (POS/DPOS)
$40 $40 no no no ded/$80 no no no ded ded ded (PPO)
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 $7 500/$15 000 $9 000/$18 000 000 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)
$15 000/$30 000 000 000 000 (PPO/DPOS) $30 $30 000/$60 000 000 000 000 (POS)
$18 000/$36 000 000 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 38