Individuals and Families Plans

$1,000 Deductible Plan

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 is included in the Membership Agreement, which will be provided to you upon acceptance.

Features

Member pays

Medical calendar-year deductible (Individual/Family)	$1,000 / $2,000
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)	$25 per visit1
Well-child visits from 0 to 23 months	$10 per visit1
Family planning visits	$25 per visit1
Eye exams	$25 per visit1
Hearing tests	$25 per visit1
Physical, occupational, and speech therapy visits	$25 per visit after deductible

Outpatient services
Outpatient surgery	$150 per procedure after deductible
Allergy injection visits	$5 per visit after deductible
Vaccines (immunizations)	No charge1
Most X-rays and lab tests	$10 per encounter after deductible

Health education
Individual visits	$25 per visit1
Group visits	No charge1

Hospitalization services
Room and board, surgery, anesthesia, X-rays, lab tests, and medications	$250 per day after deductible

Emergency health coverage
Emergency Department visits	$100 per visit after deductible (waived if admitted directly to the hospital)

Ambulance services
Emergency ambulance services	$150 per trip after deductible

Prescription drug coverage
Covered items in accord with our drug formulary when obtained at Plan pharmacies
Generic drugs	$10 up to a 30-day supply
Brand-name drugs	$35 up to a 30-day supply
Mail-order program	$20 generic/$70 brand for 100-day supply for most maintenance drugs

Durable medical equipment (DME)
DME used in the home in accord with our DME formulary	20 percent coinsurance up to a $1,000 calendar year benefit limit1
Prosthetic and orthotic devices	No charge

Mental health services

Inpatient psychiatric care Inpatient psychiatric care $250 per day after deductible (up to 30 days per calendar year)

Outpatient visits Individual visits $25 per individual visit (deductible does not apply) up to a total of 20 individual and group visits per calendar year Group therapy visits $12 per group visit (deductible does not apply) up to a total of 20 individual and group visits per calendar year Up to 20 additional group therapy visits that meet Medical Group criteria in the same 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, Deductibles, Copayments, and Coinsurance” section of the Membership Agreement.

Chemical dependency services
Inpatient detoxification	$250 per day after deductible
Outpatient individual therapy visits	$25 per visit after deductible
Outpatient group therapy visits	$5 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)	$250 per admission after deductible

Home health services
Home health care (up to 100 two-hour visits per calendar year)	No charge1

Other
Skilled nursing facility care	No charge after deductible (up to 100 days per benefit period)
Hospice care	No charge1

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