Choice Bronze Standard POS HSA
What is the cost for advanced radiology services?
10% coinsurance per service after INET plan deductible is met
What is the in network Individual deductible for this plan?
$1,300
What is the cost of In-Network and Out of Network deductibles for individuals?
Individual
In-Network: $6500
Out-of-Network: $15000
What is the cost of Generic drugs?
$10 copay per prescription
Cost for Adult Preventive Dental Care
(one dental exam and cleaning
per 6-month period)
No cost
What is the cost for Tier 2 prescriptions filled out of network?
50% coinsurance per prescription after OON plan deductible is met
What is the cost of an in network mammography ultrasound with this plan?
$20 copayment per service
What is the INET and OUTNET cost for Orthodontic services?
Orthodontic Services
In-Network: 50.00% Coinsurance after deductible when medically necessary
Out-of-Network: 50.00% Coinsurance after deductible when medically necessary
What do you pay for Prescription Eye Glasses (12 month calendar)
Lenses: $0
Collection frames: $0
Cost for Outpatient mental health, alcohol
and substance abuse treatment
No cost
What is coinsurance percentage for INET Orthodontia visits?
50% coinsurance per visit after INET plan deductible is met
How much will members pay for adult/pediatric preventative out-of-network visits?
30% coinsurance per visit
How many Chiropractic Services are allowed per year?
up to 20 visits per calendar year
Cost for Routine Eye Exam by a Specialist
(one exam per calendar year)
$60 copayment per visit
What is the INET and OON prescription drug deductible for individuals and families?
INET: $0
OON: Included in the OON deductible ($7,000 per member $14,000 per family)
What is the cost for OON allergy injection visit?
50% coinsurance per visit after OON plan deductible is met
How much does it cost to see a specialist for an opioid addiction in network?
$20
What is the cost for Artificial Limbs?
20% coinsurance after INET plan deductible is met
Cost for Mammography Ultrasound
$20 copayment per service
How many routine eye exams are covered per year and what is the cost per visit?
1 visit with a $40 copay
What is the yearly limit on a skilled nursing stay?
90 days
How much will speech therapy cost for an in-network therapist?
$20 a visit
How much will a patient under 20 pay for Prescription Eye Glasses with collection frames?
Lenses: $0 after INET plan deductible is met
Collection frames: $0 after INET plan deductible is met
Telemedicine visit (See primary care or specialist office visits)
Specialist Office Visits $60 copayment per visit
What is the cost of diabetic equipment/supplies in network?
50% coinsurance per equipment/supply