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.
Classic Choice: Services
| In-Network | Out-of-Network | |
|---|---|---|
|
OFFICE VISIT |
Option 1: For $3,000 CYD: $45 copayment* per visit Option 2: For $6,000 CYD: $45 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 Unlimited Calendar Year Maximum Per Member |
||
|---|---|---|
|
Generic 30 day supply. In-network |
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 - No waiting periods
Pediatric (Under Age 19)
- Preventative services as outlined by the United States Preventative Task Force (USPTF) and the Health Resources and Services Administration (HRSA)
- Other eligible dental services subject to CYD and coinsurance
- Limited orthodontic care
Age 19 and Over
- $40 copay for preventative and restorative services
- Maximum benefit per calendar year is $500
VISION - No waiting periods
Pediatric (Under Age 19)
- Eye exams are covered at 100% once every calendar year
- 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
- Eye exams are covered once every calendar year with a limit of $40
- 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
3 One 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