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Individuals and Families Plans
$30/$2,700 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) | $2,700 / $5,450 |
| Annual out-of-pocket maximum (Individual/Family) | $5,250 / $10,500 |
| Lifetime benefit maximum | None |
| Professional services (plan provider office visits) | |
| Primary and specialty care visits (includes routine and urgent care appointments) | $30 per visit after deductible |
| Well-child visits from 0 to 23 months | $10 per visit1 |
| Family planning visits | $30 per visit after deductible |
| Scheduled prenatal care | $10 per visit1 |
| First postpartum visit | $10 after deductible |
| Eye exams | $30 per visit after deductible |
| Hearing tests | $30 per visit after deductible |
| Chiropractic office visits | Not covered |
| Physical, occupational, and speech therapy visits | $30 per visit after deductible |
| Outpatient services | |
| Outpatient surgery | 30% coinsurance 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 visit after deductible |
| Group visits | No charge per class after deductible |
| Hospitalization services | |
| Room and board, surgery, anesthesia, X-rays, lab tests, and medications | 30% coinsurance per admission after deductible |
| Emergency health coverage | |
| Emergency Department visits | 30% coinsurance per admission after deductible (waived if admitted directly to the hospital) |
| Ambulance services | |
| Emergency ambulance services | $100 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 after deductible |
| Brand-name drugs | $30 up to a 30-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 | 30% coinsurance per admission 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 charge after deductible |
| Other | |
| Skilled nursing facility care (100 days per benefit period) | 30% coinsurance per admission after deductible |
| Hospice care | No charge after deductible |
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(1) These services not subject to the deductible. |
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