Advantage Benefit Chart for Services Incurred During Plan Years 2010 and. 13 2011 2012 and 2013. 2010 and 2011 2012 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) $50/$100 $140/$280 $350/$700 $600/$1,200 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) $17 2) $22 1) $22 2) $27 1) $27 2) $32 1) $37 2) $42 Convenience Clinic (deductible waived) $10 $10 $10 $10 2010 and 2011 2012 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: Emergency room copay $75 $75 $75 N/A – subject to Deductible and 25% Coinsurance to OOP maximum Facility copays • Per inpatient admission (waived for admission to Center of Excellence) • Per outpatient surgery $85 $55 $180 $110 $450 $220 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% 5% 10% 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) 10% (90% 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: $10 Tier 2: $16 Tier 3: $36 Tier 1: $10 Tier 2: $16 Tier 3: $36 Tier 1: $10 Tier 2: $16 Tier 3: $36 Tier 1: $10 Tier 2: $16 Tier 3: $36 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) $1,100/$2,200 $1,100/$2,200 $1,100/$2,200 $1,100/$2,200 2013 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) $75/$150 $180/$360 $400/$800 $1,000/$2,000 Office visit copay/ urgent care (copay waived for preventive services) 1) Having taken health ass...
Advantage Benefit Chart for Services Incurred During Plan Years 2010 and. 8 2011 2012 and 2013. 2010 and 2011 2012 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) $50/$100 $140/$280 $350/$700 $600/$1,200 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) $17 2) $22 1) $22 2) $27 1) $27 2) $32 1) $37 2) $42 Convenience Clinic (deductible waived) $10 $10 $10 $10
