Choice Gold Alternative POS with Dental
What is the Out-of-Pocket Maximum Individual
$6,200 per member
What would be the cost for Specialist Office Visits
$60 copayment per visit after INET plan deductible is met
What would be the cost for Individual Calendar Plan Deductible
$1,300 per member
What would be the cost for Advanced Radiology (CT/PET Scan, MRI)
50% coinsurance per service after INET plan deductible is met
What would be the cost for Plan Deductible per Family
$12,400 per family
What is cost for Mental Health and Substance Abuse Office Visits
$60 copayment per visit
What would be the cost for Mammography Ultrasound
$20 copayment per service after INET plan deductible is met
What would be the cost for Separate Prescription Drug Deductible for Family
$100 per family
What would be the cost for Non-Preferred Brand Drugs Tier 3
50% coinsurance up to $500 per prescription after INET plan deductible is met
What would be the cost for Advanced Radiology (CT/PET Scan, MRI)
$75 copayment per service after INET plan deductible met is up to a combined annual maximum of $375 for MRI and CAT scans; $400 for PET scans
What is the cost for Tier 1 Generic Drugs
$10 copayment per prescription
What would be the cost for Diabetic Equipment and Supplies
40% coinsurance per equipment/supply after INET plan deductible is met
What would be the cost for Physical and Occupational Therapy
$20 copayment per visit
What would be the cost for Home Health Care Services (up to 100 visits per calendar year)
25% coinsurance per visit
What would be the cost for Laboratory Services
$10 copayment per service after INET plan deductible is met
What is the cost for Speech Therapy
$50 copayment per visit
What would be the cost for Home Health Care Services (up to 100 visits per calendar year)
No cost
What would be the cost for Chiropractic Services (up to 20 visits per calendar year)
$40 copayment per visit
What would be the Out of Network cost for Emergency Room visit
50% coinsurance per visit after INET plan deductible is met
What would be the cost for Adult Routine Eye Exam by a Specialist – over age 20 (one exam per calendar year)
$60 copayment per visit after INET plan deductible is met
What would b e the cost for Emergency Room
20% coinsurance per visit after INET plan deductible is met
What would be the cost for Routine Eye Exam by a Specialist (one exam per calendar year)
$60 copayment per visit
What would be the cost for Outpatient Services (in a hospital or ambulatory facility)
$500 copayment per visit after INET plan deductible is met at an Outpatient Hospital Facility
$300 copayment per visit after INET plan deductible is met at an Ambulatory Surgery Center
What would be the cost for Allergy Testing (one visit per calendar year)
See primary care or specialist office visits
Answer: No cost
What would be the cost for Out of Network Telemedicine visit
50% coinsurance per visit after OON plan deductible is met