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PREMIER PLAN HMO
$99 month
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2011 BENEFIT HIGHLIGHTS* |
| Hospitalization |
Out-of-pocket limit: $1,500/year
$150/day for days 1-5
$0/day for days 6-90
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| Doctor office visits |
Primary care visit: $10 co-pay
Specialist visit: $20 co-pay
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| Emergency care |
Worldwide coverage: $50 co-pay
$0 co-pay if you are admitted to the hospital within 12 hours
$50 co-pay for ambulance
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| Urgent Care |
Anywhere in the U.S.: $10 co-pay |
| Routine physical exams |
$0 co-pay |
| Skilled nursing facility care |
Days 1-120 in a facility: $40 co-pay |
| Chiropractic services/ Acupuncture |
$20 co-pay for manual manipulation of the spine to correct subluxation
$25 co-pay for up to 5 routine chiropractic visits per year
$20 co-pay per acupuncture visit; up to 15 visits per year
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| Vision services |
Treatment of eye conditions & diseases: $20 co-pay
Routine eye exam: $20 co-pay for each; limited to 1 exam every 2 years
Eyewear: up to $125 for every 2 years
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| Preventive and diagnostic services |
$0 co-pay for:
Medicare-covered bone mass measurements, colorectal screening, flu and pneumonia vaccines
Mammograms
Pap smears
Pelvic exams
Prostate cancer screening
Diagnostic tests
X-rays
Lab services
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| Outpatient prescription drugs** (see Formulary) |
$110 deductible
$0 co-pay for: Enalapril; Lisinopril (high blood pressure); Lovastatin; Simvastatin (high cholesterol); Glipizide; Glyburide; Metformin (diabetes)
Up to $9 co-pay for generic formulary drugs
Up to $40 co-pay for preferred brand drugs
30% coinsurance for specialty drugs
Up to $80 co-pay for non-preferred drugs
You receive a discount on brand name drugs and pay 93% of the plan's costs for all generic drugs once your total drug spend reaches: $2,840
After you've spent $4,550 out-of-pocket: you will pay the greater of $2.50 and $6.30 co-pays or 5% coinsurance
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| Dental benefit |
NO.
Only available with Premier Plan Plus HMO
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| Hearing aids benefit |
NO.
Only available with Premier Plan Plus HMO
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| Out-of-pocket maximum for durable medical equipment |
NO.
Only available with Premier Plan Plus HMO
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