Page 41 - 2022 Large Group benefits

Deductible/Coinsurance Health Plan
Benefits per contract year
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-based
20 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 drugs13 15 16 Generic drugs13 16 Preferred brand drugs13 16 Non-preferred drugs13 16 Self-administered specialty drugs17
Deductible Coinsurance Out-of-pocket maximum — individual/family21
You pay in-network
10%
Personal Choice PPO PPO PPO PPO $4000/90% w Int Rx 1 $4 000/$8 000 000 $7 900/$15 800
0%
no ded
$0 no no ded/$750 no no ded
ded
Physician services 10%
after ded
10%
after ded
Hospital/other medical services 10%
after ded
Not covered
0%
no ded
10%
after ded
10%
after ded6
10%
after ded6
10%
10%
after after ded/10% after after ded
ded
10%
after ded
10%
after ded
10%
after ded
10%
after ded
10%
after after ded/30% after after ded
ded
10%
after after ded/30% after after ded
ded
10%
after ded
10%
10%
after after ded/10% after after ded
ded
10%
after ded
10%
after after ded/20% after after ded
ded
Prescription drugs12 14
$3 after ded
$20 after ded
$40 after ded
$70 after ded
50% up to $500 after ded
Out-of-network18 19
You pay out-of-network
$6 000/$12 000 000 50% after ded
$12 000/$24 000 000 2022 Large Group Plans | Independence Blue Cross 40