Individuals and Families Plans

$25 Copayment 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)	None/None
Annual out-of-pocket maximum (Individual/Family)	$2,500 / $5,000
Lifetime benefit maximum	None

Professional services (plan provider office visits)
Primary and specialty care visits (includes routine and urgent care appointments)	$25 per visit
Well-child visits from 0 to 23 months	No charge
Family planning visits	$25 per visit
Scheduled prenatal care and first postpartum visit	No charge
Eye exams	$25 per visit
Hearing tests	$25 per visit
Physical, occupational, and speech therapy visits	$25 per visit

Outpatient services
Outpatient surgery	$100 per procedure
Allergy injection visits	$5 per visit
Vaccines (immunizations)	No charge
Most X-rays and lab tests	$10 per encounter

Health education
Individual visits	$25 per visit
Group visits	No charge

Hospitalization services
Room and board, surgery, anesthesia, X-rays, lab tests, and medications	$200 per day

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

Ambulance services
Emergency ambulance services	$100 per trip

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	Not covered
Prosthetic and orthotic devices	No charge

Mental health services

Inpatient psychiatric care Inpatient psychiatric care $200 per day (up to 30 days per calendar year)

Outpatient visits Individual visits $25 per visit (up to 20 individual/group visits per calendar year) Group therapy visits $12 per visit (up to 20 individual/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, Copayments, and Coinsurance” section of the Membership Agreement.

Chemical dependency services
Inpatient detoxification	$200 per day
Outpatient individual therapy visits	$25 per visit
Outpatient group therapy visits	$5 per visit
Transitional residential recovery services (up to 60 days per calendar year, not to exceed 120 days in any five-year period)	$100 per admission

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

Other
Skilled Nursing Facility care	No charge (up to 100 days per benefit period)
Hospice care	No charge

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