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)

$6,850 individual / $13,700 family for federally required essential health benefits

Only applies to durable medical equipment, certain hearing aids and cochlear implants

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%

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

Oral Surgery

Plan pays 100%

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

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