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Individuals and Families Plans
$1,500 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) | $1,500 / $3,000 |
| Annual out-of-pocket maximum (Individual/Family) | $3,500 / $7,000 |
| Lifetime benefit maximum | None |
| Professional services (plan provider office visits) | |
| Primary and specialty care visits (includes routine and urgent care appointments) | $30 per visit1 |
| Well-child visits from 0 to 23 months | $30 per visit1 |
| Family planning visits | $30 per visit1 |
| Eye exams | $30 per visit1 |
| Hearing tests | $30 per visit1 |
| Physical, occupational, and speech therapy visits | $30 per visit after deductible |
| Outpatient services | |
| Outpatient surgery | $250 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 | $30 per visit1 |
| Group visits | No charge1 |
| Hospitalization services | |
| Room and board, surgery, anesthesia, X-rays, lab tests, and medications | $500 per day after deductible |
| Emergency health coverage | |
| Emergency Department visits | $150 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 | 30% coinsurance |
| 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 | $500 per day after deductible |
| Outpatient individual therapy visits | $30 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) | $100 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 | $50 per day after deductible (up to 60 days per benefit period) |
| Hospice care | No charge1 |
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(1) These services not subject to the deductible. (2) When prescribed by American Specialty Health (ASH) Plans practicing chiropractor and authorized by ASH Plan. |
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