| |
Heritage Preferred Plus 30 |
| 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 |
30% |
50% |
Annual Coinsurance Maximum PCY
Once met, Preferred Providers covered in full. |
$3,000 |
Unlimited |
| Lifetime Benefit Maximum |
$2,000,000 per individual |
| PREVENTIVE CARE |
| Preventative Care Exams |
Covered in full3
$200 PCY |
Not covered |
| Immunizations |
| PROFESSIONAL CARE |
Office Visit
Including Urgent Care |
30% |
50% |
| Other Outpatient Professional Services |
30% |
50% |
| Inpatient Professional Care |
30% |
50% |
| PHARMACY |
Prescription Drug Benefit $5,000 PCY (If applicable)
separate annual deductible applies; prescriptions
limited to 30-day supply |
After $500 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 |
30% |
50% |
| Mammography |
30% |
50% |
Cancer Screening and Cholesterol Screening
Includes pap smears, PSA testing, home colon cancer
screening and cholesterol screening |
Deductible waived; 30% |
50% |
| FACILITY CARE |
| Inpatient Facility Care |
30% |
50% |
| Outpatient Facility Care |
30% |
50% |
| Skilled Nursing Facility |
30%
20 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 30% |
| Ambulance Transportation |
30% ($5,000 PCY) |
| OTHER SERVICES |
Maternity Care
Including prenatal care |
Not covered |
| Spinal & Other Manipulations |
30%
12 visits PCY |
50%
(limit shared with in-network) |
| Acupuncture |
30%
12 visits PCY |
50%
(limit shared with in-network) |
| Supplies, Equipment and Prosthetics |
30%
$5,000 PCY |
50%
(limit shared with in-network) |
| Home Health Care |
30%
130 home health visits PCY |
50%
(limit shared with in-network) |
Hospice Care
|
30%
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 |
30%
Outpatient: 15 visits PCY; Inpatient: 10 days PCY |
50%
(limit shared with in-network) |
Transplants (Organ & Bone Marrow)
$250,000 lifetime benefit maximum; 12-month waiting
period |
30% |
Not covered |
PCY = Per Calendar Year 
Asuris
NW Health
