|
| Covered Services |
Gold
Choice 261 |
GCH 262 |
| Monthly premium |
49 |
48 |
| Prescription Drugs |
|
|
| - Deductible |
$0 |
$295 |
| - Tier 1 |
$7
copay* |
25% |
| - Tier 2 |
$40
copay |
25% |
| - Tier 3 |
$60
copay |
25% |
| - Tier 4 |
33% |
25% |
| Office visits |
|
|
| PCP |
$15 |
$15 |
| Specialist |
$30 |
$30 |
| X-Rays |
$15 |
$15 PCP/$30 Spec |
| Laboratory services |
$15 |
$15 PCP/$30 Spec |
| Inpatient Hospital |
$950 copayment |
$950 copayment |
|
for each hospital stay |
for each hospital stay |
| Outpatient Surgery |
$100 |
20% |
| Emergency Room |
$50 |
20% up $50 |
| Urgent Care |
$15 |
$15 |
| Ambulance Services |
$100 |
20% |
| Preventive Care |
|
|
| - Annual Physical Exam |
$0 |
$0 |
| - Immunizations |
$0 |
$0 |
| - GYN exams |
$0 |
$0 |
| - Screening Mammograms |
$0 |
$0 |
| - Bone Mass Measurements |
$0 |
$0 |
| - Colorectal Screening Exams |
$0 |
$0 |
| - Prostate Screening Exams |
$0 |
$0 |
| Vision |
n/a |
n/a |
| Hearing |
n/a |
n/a |
| Dental |
n/a |
n/a |
| * Mail order $0 for 90day supply |
|
|
|
 |
|
|
|
|
|
Health/Wellness Education:
- Written health education materials
- Additional Smoking Cessation*
- Health Club Membership/Fitness Class
- Nursing Hotline
PrescribIT Mail-order pharmacy discounts on over-the-counter products (non-prescription).
Discounts thru participating EyeMed providers
NutriSystem Silver Discount
|
|
|
|
|
