Page 49 - 2022 Large Group benefits

Choice Advantage Health Plans
Benefits per contract year
You pay in-network
Personal Choice PPO CA $3 000/$25/$65/80% 1 You pay in-network
Personal Choice PPO CA $4 000/$30/$75/90% 1 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
$4 000/$8 000 000 10% $7 900/$15 800
$0
no ded $0/$750
no ded $30 no no ded/$20 no no ded ded $75 no no ded/$50 no no ded ded $30 no ded Not covered $0
no ded $100 no ded $75 no ded6
$50 no no ded/$150 no no ded6
10% 10% after after ded/10% after after ded ded $300 after ded $300 after ded $50 no no ded/$150 no no ded ded $200 no no ded/$400 no no ded ded $150 no no ded/$300 no no ded ded 10% after after ded/30% after after ded ded 10% after ded $75 no ded/10% after ded ded 10% after after ded/30% after after ded ded $50 no no ded/$150 no no ded ded See prescription drug plans on on page 57
You pay out-of-network
$6 000/$12 000 000 50%
after ded $12 000/$24 000 000 $3 000/$6 000 000 20%
$7 900/$15 800
$0
no ded $0/$750
no ded Physician services $25 no no ded/$20 no no ded ded $65 no no ded/$45 no no ded ded $25 no ded Not covered $0
no ded $100 no ded $65 no ded6
$40 no no ded/$100 no no ded6
Hospital/other medical services 20%
20%
after after ded/20% after after ded ded $300 after ded $300 after ded $40 no no ded/$100 no no ded ded $100 no no ded/$200 no no ded ded $150 no no ded/$300 no no ded ded 20%
after after ded/40% after after ded ded 20%
after ded $65 no ded/20% after ded ded 20%
after after ded/30% after after ded ded $40 no no ded/$100 no no ded ded 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 $10 000/$20 000 000 2022 Large Group Plans
| Independence Blue Cross 48