The table below lists costs for common services for each It's Your Choice plan design option. Your Certificate of Coverage details all of your benefits.

Regular out-of-network services are only available through the Local Access Plan. The Local Traditional Plan offers out-of-network services only for emergency or urgent care.
 

In-Network Services

Local Traditional & Local Access Plan

Out-of-Network Services

Local Access Plan

Annual Medical Deductible

No deductible

$500 individual / $1,000 family

When an individual within a family plan meets the $500 deductible, coinsurance will apply to covered medical services

Medical deductible does not apply to prescription drugs

Annual Medical Coinsurance

Plan pays 100% for most services, except for durable medical equipment, certain hearing aids and cochlear implants

After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL

Annual Medical Maximum Out-of-Pocket Limit (OOPL)

Only applies to durable medical equipment (see separate OOPL below), certain hearing aids and cochlear implants
$6,850 individual / $13,700 family for federally required essential health benefits

None

Routine, preventive services as required by federal law

Plan pays 100%

For details, visit
healthcare.gov

After deductible plan pays 80%, you pay 20% coinsurance to OOPL

Illness/injury related services

Plan pays 100%

After deductible: Plan pays 80%, you pay 20% coinsurance to OOPL

Emergency Room Copay

(Waived if admitted as an inpatient directly from the emergency room or for observation for 24 hours or longer.)

You pay $60 copay per visit

You pay $75 copay, the in-network deductible applies to services after the copay

Vision Exam

Plan pays 100% for one routine exam per year; plan pays 100% for exams related to illness or injury

Routine exam: No benefit

Illness or injury: After deductible plan pays 80% for adults or children; you pay 20% coinsurance to OOPL

Hearing Exam

Plan pays 100%

After deductible: Plan pays 80% only when exam is for illness or disease; you pay 20% coinsurance to OOPL

Hearing Aid
(per ear)

Every 3 years:
Adults: Plan pays 80% up to $1,000 benefit limit, you pay 20% coinsurance for the first $1,000 and the full cost after

Children: Plan pays 100%

Every 3 years:
Adults: No benefit

Children: After deductible, plan pays 80%; you pay 20% coinsurance to OOPL

Cochlear Implants

Adults: Plan pays 80%, you pay 20% coinsurance for device, surgery, follow-up sessions (not to OOPL); plan pays 100% for hospital charge for surgery

Dependents under 18, plan pays 100% for all services

Dependents under 18, After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL for device, surgery, follow-up sessions

Durable Medical Equipment

Plan pays 80%, you pay 20% coinsurance up to $500 OOPL per person

After deductible: Plan pays 80%, you pay 20% coinsurance to OOPL

Physical/Speech/Occupational Therapy

Plan pays 100% for a combined 50 visits per year (amongst all therapies); plan may approve an additional 50 visits per therapy type per year

After deductible: Plan pays 80% you pay 20% coinsurance to OOPL for a combined 50 visits per year (amongst all therapies); plan may approve an additional 50 visits per therapy type per year

Skilled Nursing Facility
(non-custodial care)

Plan pays 100% for 120 days per benefit period

After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL for 120 days per benefit period

Home Health
(Non-custodial)

Plan pays 100% for 50 visits per year

Plan may approve an additional 50 visits

After deductible: Plan pays 80% and you pay 20% coinsurance up to OOPL for 50 visits per plan year

Plan may approve an additional 50 visits

Mental Health/Alcohol & Drug Abuse

Outpatient, inpatient and covered transitional services. Plan pays 100%

Outpatient, inpatient and covered transitional services. After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL

Transplants

Plan pays 100%

After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL

Precertification for hospitalizations, high-tech radiology and low back surgery

Varies by plan

See plan descriptions and contact your plan

Varies by plan

See plan descriptions and contact your plan

Referrals

In-network varies by plan

See plan descriptions and contact your plan

Out-of-network: Referral is required

Not required

Treatment for morbid obesity

Excluded

Excluded

Oral Surgery

Plan pays 100%

After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL

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