$0/$2,700 Deductible Plan with HSA

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Features Member pays
Medical calendar-year deductible (Individual/Family) $1,500 / $3,000
Annual out-of-pocket maximum (Individual/Family) $1,500 / $3,000
Lifetime benefit maximum None

 

Professional services (plan provider office visits)
Primary and specialty care visits (includes routine and urgent care appointments) No charge per visit after deductible
Well-child visits from 0 to 23 months No charge1
Family planning visits No charge per visit after deductible
Scheduled prenatal care No charge1
First postpartum visit No charge after deductible
Eye exams No charge per visit after deductible
Hearing tests No charge per visit after deductible
Physical, occupational, and speech therapy visits No charge per visit after deductible

 

Outpatient services
Outpatient surgery No charge per procedure after deductible
Allergy injection visits No charge after deductible
Vaccines (immunizations) No charge1
Most X-rays and lab tests No charge after deductible

 

Health education
Individual visits No charge per visit after deductible
Group visits No charge per class after deductible

 

Hospitalization services
Room and board, surgery, anesthesia, X-rays, lab tests, and medications No charge per admission after deductible

 

Emergency health coverage
Emergency Department visits No charge per admission after deductible

 

Ambulance services
Emergency ambulance services No charge per trip after deductible

 

Prescription drug coverage
Covered items in accord with our drug formulary when obtained at Plan pharmacies  
Generic drugs No charge up to a 100-day supply after deductible
Brand-name drugs No charge up to a 100-day supply after deductible

 

Durable medical equipment (DME)
DME used in the home in accord with our DME formulary Not covered
Prosthetic and orthotic devices No charge

 

Mental health services
 
Inpatient psychiatric care
Inpatient psychiatric care No charge per admission after deductible (up to 30 days per calendar year)
Outpatient visits
Individual visits No charge per visit after deductible (up to 20 visits per calendar year)
Group therapy visits No charge per visit after deductible(up to 20 visits per calendar year)

 

Note: Visit and day limits do not apply to severe mental illness and serious emotional disturbances of children as described in the "Benefits and Cost Sharing" section of the Membership Agreement.

 

Chemical dependency services
Inpatient detoxification No charge per admission after deductible
Outpatient individual therapy visits No charge per visit after deductible
Outpatient group therapy visits No charge per visit after deductible
Transitional residential recovery services (up to 60 days per calendar year, not to exceed 120 days in any five-year period) No charge per admission after deductible

 

Home health services
Home health care (up to 100 two-hour visits per calendar year) No charge per visit after deductible

 

Other
Skilled nursing facility care (100 days per benefit period) No charge per admission after deductible
Hospice care No charge per visit after deductible

(1) These services not subject to the deductible.