$11

$0

Annual Maximum Out-of-Pocket

(Does not include prescription drugs)

$4,100

Inpatient Hospital¹

Per admission

$280 per day, Days 1-5 $0 Days 6 and beyond

$250

$0

$30

$0

$30

Emergency Room Visit

Copayment is waived if admitted to a U.S. hospital within 24 hours

$90

$45

Diagnostic Lab Tests

$0-$15

$25

Diagnostic Tests

Such as ultrasound, EKG, stress test

$35

Radiation Therapy¹

Per service

$60

Diagnostic Radiology Services¹

Such as MRIs, CT scans

$200

Outpatient Ambulatory Surgical Center Services

Such as diagnostic colonoscopies

$250

Preventive Dental Exam²

One exam and cleaning per year, X-rays are not included

$30

Comprehensive Dental Benefit²

$38 monthly premium
Annual Maximum: $1,000

Routine Eye Exam²

One exam per year

$10

Diagnostic Eye Exam

To diagnose and treat diseases and conditions of the eye 

$30

Inpatient Mental Health¹

Per admission

$295 per day, Days 1-5 $0 Days 6 and beyond

Outpatient Mental Health
Individual or group therapy

$30

Skilled Nursing Facility¹
Per admission

$0 per day, Days 1-20 $184 per day, Days 21-49 $0 Days 50-100

Physical, Occupational, Speech Outpatient Therapy

Includes comprehensive outpatient rehabilitation facility

$30

Ambulance - Air and Ground Services

$225

Transportation - Non-Emergency
Includes 24 one-way trips for all members diagnosed with end stage renal disease (ERSD), to get to and from dialysis for treatment

Covered

20% of the cost

Medicare Part D Drugs

See prescription drug chart for tier information

Covered

Chiropractic Services

Manipulation of the spine to correct misalignment of one or more of the bones of your spine

$20

Diabetes Monitoring Supplies and Test Strips¹

OneTouch^TM and Accu-Chek^TM test strips, continuous glucose monitoring supplies limited to FreeStyle Libre^® and Dexcom^®. All other brands are not covered.

$0 for up to a 90-day supply

Dialysis
Per treatment

20% of the cost

Diabetic Shoe Inserts

Copayment per pair

$10

Durable Medical Equipment
Such as insulin pumps, CPAP machines, prosthetic devices

20% of the cost

$0

Virtual Visits²

Virtual visit for medical (including dermatology) and behavioral health through MDLIVE^®2

$0

Hearing Aids²
Includes a three-year warranty with loss and damage insurance, up to six hearing aid follow up visits within three years and 16 batteries. Maximum of two hearing aids per year.

Select hearing aids discounted to
$795-$2,370 per device.
(A savings of up to $1,050 per hearing aid)

Additional Eyewear²
Discounts offered at EyeMed providers

Discounts included

Included

$40/Quarter No rollover on quarterly allowance - one order per quarter 

Pick Your Perks Reimbursement Program²

Reimbursement for Medicare-approved supplemental benefits including dental, vision, meals, non-emergency transportation, over-the-counter items, acupuncture, massage therapy expenses and nutritional/dietary benefits

Not included

$0 for Tiers 1, 2 and 3
$260 for Tiers 4 and 5 only

30-Day Supply Preferred Pharmacy or Mail Order Pharmacy
$2 for Tier 1     $42 for Tier 3
$8 for Tier 2     $90 for Tier 4
28% of the cost for Tier 5

30-Day Supply Standard Pharmacy
$4 for Tier 1     $47 for Tier 3
$14 for Tier 2   $100 for Tier 4
28% of the cost for Tier 5

90-Day Supply Preferred Pharmacy
$5 for Tier 1       $105 for Tier 3
$20 for Tier 2     $225 for Tier 4
Tier 5 is not available

90-Day Supply Standard Pharmacy
$10 for Tier 1     $118 for Tier 3
$35 for Tier 2     $250 for Tier 4
Tier 5 is not available

31 to 90-Day Supply Mail Order Pharmacy
$0 for Tier 1

90-Day Supply Mail Order Pharmacy
$0 for Tier 1       $105 for Tier 3
$20 for Tier 2     $225 for Tier 4
Tier 5 is not available

You enter the coverage gap when total drug costs reach $4,130. You pay 25% and Network Health pays 75% for generic drugs. For brand name drugs, you pay 25%, Network Health pays 5% and the drug company pays 70%.

You enter catastrophic coverage when your true out-of-pocket costs reach $6,550. You pay the greater of $3.70 or 5% of the cost for generic drugs and $9.20 or 5% of the cost for brand name drugs.