Advantage Benefit Chart for Services Incurred During Plan Years 2020 and 2021. 2020 and 2021 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) $250/$500 $400/$800 $750/$1,500 $1,500/$3,000 2020 and 2021 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: Office visit copay/urgent care (copay waived for preventive services) For 2020: 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 For 2021: The incentive is changed and the only available copay option is copay #2. 1) $30 2) $35 1) $35 2) $40 1) $65 2) $70 1) $85 2) $90 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 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 2020 and 2021 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: Coinsurance for MRI/CT scan services 10% 15% 25% N/A – subject to Deductible and 30% 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 lab, pathology and X-ray (not included as part of preventive care and not subject to office visit or facility copayments) 10% (90% coverage after payment of deductible) 10% (90% 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: $18 Tier 2: $30 Tier 3: $55 Tier 1: $18 Tier 2: $30 Tier 3: $55 Tier 1: $18 Tier 2: $30 Tier 3...
Advantage Benefit Chart for Services Incurred During Plan Years 2020 and 2021. 2020 and 2021Benefit 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) $250/$500 $400/$800 $750/$1,500 $1,500/$3,000 Office visit copay/urgent care (copay waived for preventive services) For 2020
