Page 48 - 2022 Large Group benefits

Choice Advantage Health Plans
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
$0
0% $7 900/$15 800
$0
$0/$750
$40/$30 $85/$60 $40 Not covered $0
$100 $856
$50/$1506
$500 per day10/$0
$300 $300 $50/$150 $200/$400
$150/$300
$40/$80 50%
$85/$500 per day10 $350/$700 $0/$170
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
Preventive services4
0% $7 900/$15 800
$0
Physician services $0/$750
$40/$30 $85/$60 $40 $405
$0
$100 $857
$857
Hospital/other medical services $500 per day10/$0
$300 $300 $857
$300 $150/$300
$40/$80 50%
$85/$500 per day10 $350/$700 $0
Prescription drugs See prescription drug plans on on page 57
Out-of-network 18 19
You pay out-of-network
$5 000/$10 000 000 50%
after ded $30 000/$60 000 000 47
Keystone POS CA $40/$85/$500 1 Personal Choice PPO CA $40/$85/$500 1