Advantage Benefit Chart for Services Incurred During Plan Years 2018 and 2019. 2018 and 2019 Benefit Provision Benefit Level 1 The member pays: Benefit Level 2 The member pays: Benefit Level 3 The member pays: Benefit Level 4 The member pays: Deductible for all services except drugs and preventive care (S/F) $150/$300 $250/$500 $550/$1,100 $1,250/$2,500 Office visit copay/urgent care (copay waived for preventive services) 1) Having taken health assessment and opted-in for health coaching 2) Not having taken health assessment or not having opted-in for health coaching 1) $25 2) $30 1) $30 2) $35 1) $60 2) 65 1) $80 2) $85 In-Network Convenience Clinics and Online Care (deductible waived) $0 $0 $0 $0 Emergency room copay $100 $100 $100 N/A – subject to Deductible and 25% Coinsurance to OOP maximum 2018 and 2019 Benefit Provision Benefit Level 1 The member pays: Benefit Level 2 The member pays: Benefit Level 3 The member pays: Benefit Level 4 The member pays: Facility copays • Per inpatient admission (waived for admission to Center of Excellence) • Per outpatient surgery $100 $60 $200 $120 $500 $250 N/A – subject to Deductible and 25% Coinsurance to OOP maximum N/A – subject to Deductible and 25% Coinsurance to OOP maximum Coinsurance for MRI/CT scan services 5% 10% 20% N/A – subject to Deductible and 25% Coinsurance to OOP maximum Coinsurance for services NOT subject to copays 5% (95% coverage after payment of deductible) 5% (95% coverage after payment of deductible) 20% (80% coverage after payment of deductible) 25% for all services to OOP maximum after deductible Coinsurance for durable medical equipment 20% (80% coverage after payment of 20% coinsurance) 20% (80% coverage after payment of 20% coinsurance) 20% (80% coverage after payment of 20% coinsurance) 25% for all services to OOP maximum after deductible Copay for three-tier prescription drug plan Tier 1: $14 Tier 2: $25 Tier 3: $50 Tier 1: $14 Tier 2: $25 Tier 3: $50 Tier 1: $14 Tier 2: $25 Tier 3: $50 Tier 1: $14 Tier 2: $25 Tier 3: $50 Maximum drug out- of-pocket limit (S/F) $800/$1,600 $800/$1,600 $800/$1,600 $800/$1,600 Maximum non-drug out-of-pocket limit (S/F) $1,200/$2,400 $1,200/$2,400 $1,600/$3,200 $2,600/$5,200
