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Individuals and Families Plans
$0/$1,500 Deductible Plan With HSA
This is a summary of the most frequently asked-about benefits and their copayments and coinsurance. For information on benefits, copayments, and coinsurance, please refer to the Disclosure Form. Detailed information about your plan in included in the Membership Agreement, which will be provided to you upon acceptance.
| 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 after deductible |
| Well-child visits from 0 to 23 months | No charge1 |
| Family planning visits | No charge after deductible |
| Scheduled prenatal care | No charge1 |
| First postpartum visit | No charge after deductible |
| Eye exams | No charge after deductible |
| Hearing tests | No charge after deductible |
| Chiropractic office visits | Not covered |
| Physical, occupational, and speech therapy visits | No charge after deductible |
| Outpatient services | |
| Outpatient surgery | No charge 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 after deductible |
| Group visits | No charge after deductible |
| Hospitalization services | |
| Room and board, surgery, anesthesia, X-rays, lab tests, and medications | No charge after deductible |
| Emergency health coverage | |
| Emergency Department visits | No charge after deductible |
| Ambulance services | |
| Emergency ambulance services | No charge 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 | |||||||
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| Note: Visit and day limits do not apply to severe mental illness and serious emotional disturbances of children as described in the “Benefits, Deductibles, Copayments, and Coinsurance” section of the Membership Agreement. |
| Chemical dependency services | |
| Inpatient detoxification | No charge after deductible |
| Outpatient individual therapy visits | No charge after deductible |
| Outpatient group therapy visits | No charge 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 after deductible |
| Home health services | |
| Home health care (up to 100 two-hour visits per calendar year) | No charge after deductible |
| Other | |
| Skilled nursing facility care (100 days per benefit period) | No charge after deductible |
| Hospice care | No charge after deductible |
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(1) These services not subject to the deductible. |
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