Advantage Benefit Chart for Services Incurred. During Plan Years 2016 2017 and 2017 2018. 20162017-20172018 Benefit Provision Benefit Xxxxx 0 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) $10 $10 $10 $10 Emergency room Copay $100 $100 $100 N/A – subject to Deductible and 25% Coinsurance to OOP maximum Facility copays N/A—subject 20162017-20172018 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: · Per inpatient Admission (waived for admission to Center of Excellence) · Per outpatient Surgery $100 $60 $200 $120 $500 $250 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
Advantage Benefit Chart for Services Incurred. During Plan Year 2010 and 42 20112012 and 2013. 43 45 2010 and 2011 Benefit Provision 2012 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) $50/$100 $140/$280 $350/$700 $600/$1200 Office visit copay/urgent care (copay waived for 1) $17 2) $22 1) $22 2) $27 1) $27 2) $32 1) $37 2) $42 preventive services)
