Page 50 - 2022 Large Group benefits

Tiered Network Health Plans
Benefits per contract year
You pay in-network — Tier 1
You pay in-network — Tier 2
You pay in-network — Tier 1
Personal Choice PPO Tiered $40-$80/90% 1
You pay in-network — Tier 2
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)6
Physical/occupational therapy (30 visits per year) Freestanding/Hospital-based6
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
$5 000/$10 000 000 30% $7 900/$15 800
0% $0/$750
$40 no no ded/$30 no no ded ded $80 no no ded/$55 no no ded ded $40 no ded Not covered
0% no ded $100 no ded $80 no ded $80 no ded 30% 30% after after ded/ 30% 30% after after ded ded $300 no ded $300 no ded $80/30% after ded $300/30% after ded $150/$300 no ded 10%/30% no ded 10% no ded $80 no no ded/ 10% no no ded ded 30% after ded $80/30% after ded See prescription drug plans on on page 57
$7 500/$15 000 50% $15 000/$30 000 000 $0 $2 500/$5 000 $7 900/$15 800
$0 10% 20%
10% $7 900/$15 800
$7 900/$15 800
Preventive services4
0% 0% 0% Physician services $0/$750
$0/$750
$0/$750
$30/$20
$30 no no ded/$20 no no ded ded $40/$30
$60/$40
$60 no no ded/$40 no no ded ded $80/$55
$30 $30 no ded $40 Not covered
Not covered
Not covered
0% $500 per day10/10%
0% no ded 0% $100 $100 no ded $100 $60 $60 no ded $60 no ded $80 $60 $80 Hospital/other medical services 20%
20%
after after ded/ 20%
20%
after after ded ded 10%/10%
$200
$200
no ded $300 $200
$200
no ded $300 $60 $60/20% after ded $80 $200
$200/20% after ded $300 $150/$300 $150/$300 no ded $150/$300 Prescription drugs 10%/30% 10%/30% no ded 10%/30% 10% $60/$500 per day10 10% no ded 10% $60 no ded/ $500 per day no no ded10
$80/10%
$500 per day $60 20%
after ded $60/20% after ded 10% $80 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
$5 000/$10 000 000 $5 000/$10 000 000 $7 500/$15 000 50% 50% 50% $10 000/$20 000 000 $10 000/$20 000 000 $15 000/$30 000 000 49
Personal Choice PPO Tiered $30-$60/$500 1