Advantage Benefit Chart for Services Incurred During Plan Years 2018 and 2019 Sample Clauses

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
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