|
Heritage Preferred Plus 20
|
| Deductible, coinsurance and copay represent
WHAT YOU PAY. Benefits apply after calendar year deductible
is met, unless otherwise noted. |
| |
In-Network
|
Out-of-Network
|
| Annual Deductible PCY |
$1,000
|
Shared with in-network deductible
|
| Coinsurance |
20%
|
50%
|
Annual Coinsurance Maximum PCY
( Once met, Preferred Providers covered in full.) |
$2,000
|
Unlimited
|
| Lifetime Benefit Maximum |
$2,000,000 per individual
|
| PREVENTIVE CARE |
| Preventative Care Exams |
Covered in full3
$300 PCY
|
Not covered
|
| Immunizations |
| PROFESSIONAL CARE |
Office Visit
(including Urgent Care) |
20%
|
50%
|
| Other Outpatient Professional Services |
20%
|
50%
|
| Inpatient Professional Care |
20%
|
50%
|
| PHARMACY |
Prescription Drug Benefit $5,000 PCY (If applicable)
separate annual deductible applies; prescriptions
limited to 30-day supply |
After $200 prescription drug deductible, member pays:
Tier 1 = 20% (generic drugs);
Tier 2 = 30% (preferred brand-name drugs);
Tier 3 = 50% (non-preferred brand-name drugs)
|
| VISION CARE |
| Routine Vision Exam |
Covered in full3
One exam per 2 calendar years
|
Vision Hardware
(frames, lenses and contacts)
|
Covered in full3
$200 per 2 calendar years
|
| DIAGNOSTIC SERVICES |
| Diagnostic Imaging & Laboratory Services |
20%
|
50%
|
| Mammography |
20%
|
50%
|
Cancer Screening and Cholesterol Screening
(includes pap smears, PSA testing, home colon cancer
screening and cholesterol screening). |
Deductible waived; 20%
|
50%
|
| FACILITY CARE |
| Inpatient Facility Care |
20%
|
50%
|
| Outpatient Facility Care |
20%
|
50%
|
| Skilled Nursing Facility |
20%
45 days PCY
|
50%
(limit shared with in-network)
|
| EMERGENCY CARE |
Emergency Room Care
(Copay waived if direct admit to an inpatient facility) |
$100 Copay plus 20%
|
| Ambulance Transportation |
20% ($5,000 PCY)
|
| OTHER SERVICES |
Maternity Care
including prenatal care |
Not covered
|
| Spinal & Other Manipulations |
20%
12 visits PCY
|
50%
(limit shared with in-network)
|
| Acupuncture |
20%
12 visits PCY
|
50%
(limit shared with in-network)
|
| Supplies, Equipment and Prosthetics |
20%
$5,000 PCY
|
50%
(limit shared with in-network)
|
| Home Health Care |
20%
130 home health visits PCY
|
50%
(limit shared with in-network)
|
Hospice Care
|
20%
Inpatient: 10 days max; Respite: 240 hrs max
|
50%
(limit shared with in-network)
|
Rehabilitation
(including Physical, Occupational, Speech and Massage
Therapy; Cardiac & Pulmonary Rehab.; and Chronic Pain) |
20%
Outpatient: 20 visits PCY; Inpatient: 8 days PCY
|
50%
(limit shared with in-network)
|
Transplants (Organ & Bone Marrow)
$250,000 lifetime benefit maximum; 12-month waiting
period |
20%
|
Not covered
|
PCY = Per Calendar Year 
Asuris
NW Health
