Monthly premium |
$0 |
$27 |
Deductible |
$0 |
$0 |
MOOP (maximum out-of-pocket) |
$7,500 annually, $11,300 combined |
$6,500 in-network, $11,000 combined |
Primary care visit |
In-network $5 | Out-of-network $5 |
In-network $5 | Out-of-network $5 |
Specialist visit |
In-network $40 | Out-of-network $40 |
In-network $25 | Out-of-network $25 |
Inpatient hospital |
$250 copay per day for days 1-7 |
$315 copay per admit |
Emergency care in U.S. |
$90 |
$90 |
Worldwide emergency coverage (annual) |
$20,000 maximum annual benefit - combined for emergency and urgent care coverage |
$20,000 maximum annual benefit - combined for emergency and urgent care coverage |
Routine vision |
One eye exam per calendar year: In-network $20 copay / Out-of-network 50% coinsurance. |
One eye exam per calendar year: In-network $20 copay / Out-of-network 50% coinsurance. |
Routine eyewear |
Up to $125 combined allowance, every year |
Up to $125 combined allowance, every year |
Routine hearing |
In-network $0 / Out-of-network 50% coinsurance for routine hearing exam and hearing aid fitting evaluation ($400 allowance every 3 years for hearing aids). |
In-network $0 / Out-of-network 50% coinsurance for routine hearing exam and hearing aid fitting evaluation ($800 allowance every 3 years for hearing aids). |
Routine dental |
Two cleanings per calendar year (cleaning and x-rays covered): In-network $10 copay / Out-of-network 50% coinsurance. |
Two cleanings per calendar year (cleaning and x-rays covered): In-network $10 copay / Out-of-network 50% coinsurance. |
Comprehensive dental services |
In-network and Out-of-Network: $2,000 maximum combined plan benefit per calendar year. 50% coinsurance for the following covered services: Palliative emergency treatment Periapical x-rays Amalgam and composite fillings Simple (nonsurgical) extractions Endodontics Major restorative (crowns, inlays, onlays) prosthodontics (including dentures) Adjustment and repairs of prosthetics |
In-network and Out-of-Network: $2,000 maximum combined plan benefit per calendar year. 50% coinsurance for the following covered services: Palliative emergency treatment Periapical x-rays Amalgam and composite fillings Simple (nonsurgical) extractions Endodontics Major restorative (crowns, inlays, onlays) prosthodontics (including dentures) Adjustment and repairs of prosthetics |
Flexible debit card for OTC drugs and supplies1 |
$25 plan allowance per month - retail or mail order (cannot be carried over month to month) |
$25 plan allowance per month - retail or mail order (cannot be carried over month to month) |
Transportation benefit |
Not Included. |
$0 Copay/24 plan approved round trips |
In-home support services: PaPa on Demand |
Not Included. |
$0 Copay/5 hours per month included. |
Medical nutritional therapy |
24 visits a year: In-network $0 copay / Out-of-network 50% coinsurance |
24 visits a year: In-network $0 copay / Out-of-network 50% coinsurance |
Nutritional/Dietary benefits |
$0 Copay |
$0 Copay |
Food and produce2 |
$20 allowance per month (Member must have diabetes, chronic lung disorder, congestive heart failure or cardiovascular disease) |
$20 allowance per month (Member must have diabetes, chronic lung disorder, congestive heart failure or cardiovascular disease) |
AmWell online doctors |
$0 Copay |
$0 Copay |
Health coaching and education benefit |
$0 Copay |
$0 Copay |
SilverSneakers® fitness program3 |
$0 Copay |
$0 Copay |
Services supporting self-direction |
$0 Copay |
$0 Copay
|