| |
Heritage Protector 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 (choose one) |
$500 or $1,000 |
$1,000 or $2,0001 |
| Coinsurance |
20% |
50% |
Annual Coinsurance Maximum PCY
Once met, Preferred Providers covered in full. |
$2,000 or $6,000 |
Unlimited |
| Lifetime Benefit Maximum |
$2,000,000 per individual |
| PREVENTIVE CARE |
| Preventative Care Exams |
20%
(Deductible waived; 1 visit PCY) |
50%
(limit shared with in-network) |
| Immunizations |
Not covered |
| PROFESSIONAL CARE |
Office Visit
Including Urgent Care |
Not Covered |
| Other Outpatient Professional Services |
20%4 |
50%4 |
| Inpatient Professional Care |
20% |
50% |
| PHARMACY |
Prescription Drug Benefit $5,000 PCY (If applicable)
separate annual deductible applies; prescriptions
limited to 30-day supply |
Not covered |
| VISION CARE |
| Routine Vision Exam |
Not covered |
Vision Hardware
Frames, lenses and contacts
|
Not covered |
| DIAGNOSTIC SERVICES |
| Diagnostic Imaging & Laboratory Services |
20%4 |
50%4 |
| 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%4 |
50%4 |
| Skilled Nursing Facility |
20%
7 days PCY |
50%
(limit shared with in-network) |
| EMERGENCY CARE |
Emergency Room Care
Copay waived if direct admit to an inpatient facility |
$20% |
| Ambulance Transportation |
20% ($500 PCY) |
| OTHER SERVICES |
Maternity Care
Including prenatal care |
Not covered |
| Spinal & Other Manipulations |
Not covered |
| Acupuncture |
Not covered |
| Supplies, Equipment and Prosthetics |
20%4 |
50%4 |
| Home Health Care |
20%
60 home health visits PCY |
50%
(limit shared with in-network) |
Hospice Care
|
20% |
50% |
Rehabilitation
Including Physical, Occupational, Speech and Massage
Therapy; Cardiac & Pulmonary Rehab.; and Chronic Pain |
20%
Inpatient only, 15 days PCY |
50%
(limit shared with in-network) |
Transplants (Organ & Bone Marrow)
$250,000 lifetime benefit maximum; 12-month waiting
period |
20%4 |
Not covered |
PCY = Per Calendar Year 
Asuris
NW Health
