$0
$0
$25
$25
$0
$0
$3,600
$3,600
$3,600
$3,600
$5,500
$5,500
No Medical or Rx Deductible
No Medical or Rx Deductible
No Medical or Rx Deductible
No Medical or Rx Deductible
No Medical or Rx Deductible
No Medical or Rx Deductible
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$30 Copay
$30 Copay
$30 Copay
$30 Copay
$45 Copay
$45 Copay
$60 Copay
$60 Copay
$60 Copay
$60 Copay
$60 Copay
$60 Copay
$90 Copay
$90 Copay
$90 Copay
$90 Copay
$90 Copay
$90 Copay
$10 Copay
$10 Copay
$10 Copay
$10 Copay
$10 Copay
$10 Copay
100% Coverage
100% Coverage
100% Coverage
100% Coverage
100% Coverage
100% Coverage
$20 Copay
$20 Copay
$20 Copay
$20 Copay
$20 Copay
$20 Copay
$200 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond
$200 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond
$200 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond
$200 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond
$350 Per Day for Days 1-5,
$0 Per Day for Day 6 and Beyond
$350 Per Day for Days 1-5,
$0 Per Day for Day 6 and Beyond
$150 Copay
$150 Copay
$150 Copay
$150 Copay
$200 Copay
$200 Copay
$100 Copay
$100 Copay
$100 Copay
$100 Copay
$150 Copay
$150 Copay
$200 allowance per year
$400 allowance per year
$200 allowance per year
Preventive and Comprehensive services combined annual allowance $1,000
Preventive and Comprehensive services combined annual allowance $2,000
Preventive and Comprehensive services combined annual allowance $1,500
$75 Per Quarter
$110 Per Quarter
$90 Per Quarter
$1,000 allowance for up to 2 hearing aids every 2 years (both ears combined)
$1,500 allowance for up to 2 hearing aids every 2 years (both ears combined)
$1,000 allowance for up to 2 hearing aids every 2 years (both ears combined)
$0 copay for 20 one-way trips to approved locations per year
$0 copay for 30 one-way trips to approved locations per year
$0 copay for 20 one-way trips to approved locations per year
Included at no additional cost
Included at no additional cost
Included at no additional cost
Emergency or urgent care coverage if you are making a trip out of state or country
Emergency or urgent care coverage if you are making a trip out of state or country
Emergency or urgent care coverage if you are making a trip out of state or country
28 meals (2 meals/day for 14 days) delivered to the home after each discharge (limited to 2 discharges annually)
28 meals (2 meals/day for 14 days) delivered to the home after each discharge (limited to 2 discharges annually)
28 meals (2 meals/day for 14 days) delivered to the home after each discharge (limited to 2 discharges annually)
No Deductible
No Deductible
No Deductible
Preferred Pharmacies - $0 Copay*
Other Network Pharmacies - $5 Copay*
Preferred Pharmacies - $0 Copay*
Other Network Pharmacies - $5 Copay*
Preferred Pharmacies - $0 Copay*
Other Network Pharmacies - $5 Copay*
Preferred Pharmacies - $0 Copay*
Other Network Pharmacies - $10 Copay*
Preferred Pharmacies - $0 Copay*
Other Network Pharmacies - $10 Copay*
Preferred Pharmacies - $0 Copay*
Other Network Pharmacies - $20 Copay*
Preferred Pharmacies - $40 Copay*
Other Network Pharmacies - $45 Copay*
Preferred Pharmacies - $40 Copay*
Other Network Pharmacies - $45 Copay*
Preferred Pharmacies - $42 Copay*
Other Network Pharmacies - $47 Copay*
Preferred Pharmacies - $90 Copay*
Other Network Pharmacies - $95 Copay*
Preferred Pharmacies - $90 Copay*
Other Network Pharmacies - $95 Copay*
Preferred Pharmacies - $95 Copay*
Other Network Pharmacies - $100 Copay*
Preferred & Other Network Pharmacies - 33% Co-insurance
Preferred & Other Network Pharmacies - 33% Co-insurance
Preferred & Other Network Pharmacies - 33% Co-insurance
$5,030 (Once the ICL is reached, the CMS mandated gap coverage applies, and member pays co-insurance of 25% for covered generics, 25% for covered brand)
$5,030 (Once the ICL is reached, the CMS mandated gap coverage applies, and member pays co-insurance of 25% for covered generics, 25% for covered brand)
$5,030 (Once the ICL is reached, the CMS mandated gap coverage applies, and member pays co-insurance of 25% for covered generics, 25% for covered brand)
