If you already know what coverage you need, and you’re ready to sign-up for affordable and quality coverage, we’re ready to help.
Advanced Choice: Services
| In-Network | Out-of-Network | |
|---|---|---|
|
OFFICE VISIT |
Option 1: For $1,500 CYD: $30 copayment* per visit Option 2: For $3,000 CYD: $40 copayment* per visit |
CYD/Coinsurance |
|
TELADOC |
$0 copayment per visit |
No coverage |
|
COINSURANCE |
Plan pays: 80% Your responsibility: 20% |
Plan pays: 60% Your responsibility: 40% |
|
PREVENTATIVE CARE BENEFITS |
In-Network | Out-of-Network |
|---|---|---|
|
NO WAITING PERIOD. In-network benefits |
Plan pays 100% |
Plan pays 60% |
|
Preventative Health Exam1 |
0% |
40% |
|
Annual Well Woman Exam2 |
0% |
40% |
|
Routine Colonoscopy3 |
0% |
40% |
|
Annual Routine PSA4 |
0% |
40% |
|
EMERGENCY ROOM |
$300 deductible per visit (in addition to CYD and Coinsurance) |
|
| PRESCRIPTION DRUG COVERAGE $7,500 Calendar Year Maximum Per Member |
||
|---|---|---|
|
Generic 30 day supply |
Plan pays all but copayment Your responsibility: $4 copayment5 |
Plan pays 60% Your responsibility: 40% |
|
Brand
|
Plan pays: 80% Your responsibility: 20% |
Plan pays 60% Your responsibility: 40% |
DENTAL - Six month waiting period for all members.
Routine dental services, including two exams, cleanings, x-rays and fillings per calendar year
- There is a copayment per visit and a $500 calendar year maximum per member per calendar year.
VISION
Pediatric (Under Age 19)
Routine vision benefits including eye exams, eyeglasses and contact lenses.
- No waiting period.
- Eye exams are covered at 100% once every calendar year, no dollar limit
- Eyeglass frames, eyeglass lenses or contact lenses are covered once every Calendar Year at 100% up to a maximum of $100 per Member, not subject to Deductible and Coinsurance.
Age 19 and Over
Routine vision benefits including eye exams, eyeglasses and contact lenses.
- Subject to a six month waiting period
- Eye exams are covered once every calendar year with a $40 limit per member
- Eyeglass frames, eyeglass lenses or contact lenses are covered once every Calendar Year at 100% up to a maximum of $100 per Member, not subject to Deductible and Coinsurance.
FOOTNOTES
1 Preventative health exam for adults and children and related services as outlined below and performed by the physician during the preventative health exam or referred by the physician as appropriate, including:
- Screenings and counseling services with an A or B recommendation by the United States Preventative Services Task Force (USPSTF)
- Bright Futures recommendations for infants, children and adolescents supported by the Health Resources and Services Administration (HRSA)
- Preventative care and screening for women as provided in the guidelines supported by HRSA, and
- Immunizations recommended by the Advisory Committee of Immunization Practices (ACIP) that have been adopted by the Centers for Disease Control and Prevention (CDC)
2 Annual Well Woman Exam
- Routine well woman preventative exam office visit
- Cervical cancer screening
- Screening mammography at age 40 and older, with one baseline mammogram between the ages of 35-39
- Other USPSTF screenings with an A or B rating
- Pap smears
- Bone density measurement screening
3One routine colonoscopy every ten years for members age 45 and older
4 Prostate cancer screening for men age 50 and older
5 Prescription copayment does not apply toward deductibles or out-of-pocket maximums