The table below lists costs for common services for each plan design option. Your Certificate of Coverage details all of your benefits.
In-Network Services Local Health Plan & Local Access Health Plan | Out-of-Network Services Local Access Health Plan | |
|---|---|---|
Annual Medical Deductible Individual / Family Counts toward Out-of-Pocket Limit (OOPL) | $250 / $500 Office visit copays, preventive services, and prescription drugs do not count toward your deductible After an individual within a family plan meets the $250 deductible, benefits apply | $500 / $1,000 Prescription drugs do not count toward your deductible After an individual within a family plan meets the $500 deductible, benefits apply
|
Primary Care Office Visit Additional services such as lab work, X-rays, etc. count toward the deductible and coinsurance Includes:
| $15 copay per visit up to OOPL Does not count toward deductible | After deductible, you pay 30% up to OOPL |
Specialty Office Visit Additional services such as lab work, X-rays, etc. count toward the deductible and coinsurance Includes:
| $25 copay per visit up to OOPL Does not count toward deductible | After deductible, you pay 30% up to OOPL |
Annual Medical Coinsurance Applies to medical services except for office visit or emergency room copayments and preventive services | 100% until deductible met After deductible, you pay 10% up to OOPL | 100% until deductible met After deductible, you pay 30% up to OOPL |
Medical Out-of-Pocket Limit (OOPL) Individual / Family | $1,250 / $2,500 | $2,000 / $4,000 |
Preventive Services | Plan pays 100% | Subject to the deductible and coinsurance |
| Illness/injury-related services beyond the office visit copayment (if applicable) | After deductible, you pay 10% up to OOPL Applies to medical services except for office visit or emergency room copays | After deductible, you pay 30% up to OOPL Applies to medical services except for emergency room copays |
Emergency Room Copay waived if admitted as an inpatient directly from the emergency room or for observation for 24 hours or longer | $75 copay per visit Copay counts toward OOPL. Deductible and coinsurance apply to services beyond the copay | $75 copay per visit Copay counts toward OOPL. Deductible and coinsurance may apply to services beyond the copay, up to OOPL |
| Transplants | After deductible, you pay 10% up to OOPL | After deductible, you pay 30% up to OOPL |
Mental Health/Alcohol and Drug Abuse Additional services such as lab work, assessments, etc. are subject to deductible and coinsurance | Outpatient services: $15 copay per visit Inpatient & covered transitional services: After deductible, you pay 10% up to OOPL | Outpatient, inpatient, and covered transitional services: You pay 30% up to OOPL |
| Hearing Aid (per ear) | Every three years: Dependents younger than age 18: After deductible, you pay 10% up to OOPL | Every three years: For dependents younger than age 18: After deductible, you pay 30% up to OOPL |
| Cochlear Implants | Adults: After deductible, you pay 20% (not up to OOPL) for device, surgery for implantation, and follow-up sessions; for hospital charge for surgery you pay 10% up to OOPL Dependents under age 18: After deductible, you pay 10% up to OOPL for all services | Dependents under age 18: After deductible, you pay 30% up to OOPL for device, surgery, and follow-up sessions |
| Skilled Nursing Facility (non-custodial care) | After deductible, you pay 10% up to OOPL, 120 days per benefit period | After deductible, you pay 30% up to OOPL, 120 days per benefit period |
| Home Health (non-custodial care) | After deductible, you pay 10% up to OOPL, 50 visits per plan year Plan may approve an additional 50 visits | After deductible, you pay 30% up to OOPL, 50 visits per plan year Plan may approve an additional 50 visits |
| Physical/Speech/Occupational Therapy | $15 copay for office visits Additional services such as lab work, X-rays, etc. are subject to deductible and coinsurance up to OOPL 50 combined visits per plan year Plan may approve an additional 50 combined visits per therapy type per year | After deductible, you pay 30% up to OOPL 50 combined visits per plan year Plan may approve an additional 50 combined visits per therapy type per year |
| Durable Medical Equipment | After deductible, you pay 20% up to OOPL | After deductible, you pay 30% up to OOPL |
| Precertification for hospitalizations, high-tech radiology, and low back surgery | Varies by plan. See plan descriptions and contact your plan | Contact your plan |
| Referrals | In-network: Varies by plan. See plan descriptions and contact your plan For Local Health Plan, a referral is required for any benefits to be covered out-of-network | Not required |
| Oral Surgery | After deductible, you pay 10% up to OOPL | After deductible, you pay 30% up to OOPL |
| Telemedicine Services | Varies by service type. See Telemedicine page | Varies by service type. See Telemedicine page |