| Benefit Description |
Within Physician Team |
Within Peoples Health Network |
Out-of-Network |
| INPATIENT CARE |
| Inpatient Hospital Care |
$0 |
$150/day (days 1-3) |
Medicare-level deductible, coinsurance and copays apply |
| Inpatient Mental Health Care |
$0 |
$0 |
Medicare-level deductible, coinsurance and copays apply |
| Skilled Nursing Facility |
$0/day (days 1-20); $25/day (days 21+) |
| Home Health Care |
$0 |
20% |
| OUTPATIENT CARE |
| PCP Office Visit |
$5 |
$25 |
20% |
| Specialist Office Visit (includes chiropractic and podiatry services) |
$10 |
$25 |
20% |
| Outpatient Mental Health / Substance Abuse Care |
$0/visit (visits 1-20)
45% coinsurance/visit (visits 21+) |
20% |
| Outpatient Surgery |
$0 |
$150 |
20% |
Emergency Care
(waived if admitted to inpatient hospital care) |
$50
($5,000 combined maximum for emergency and urgent care services outside the U.S.) |
| Ambulance Service |
$0 |
$50 |
Urgently Needed Care
(within U.S.) |
$10
|
| Urgently Needed Care (outside of U.S.) |
$50
($5,000 combined maximum for emergency and urgent care services outside the U.S.) |
| Outpatient Rehabilitation Services (includes occupational, physical and speech therapy) |
$0 (Medicare limits apply) |
$0 (Medicare limits apply) |
20% (Medicare limits apply) |
| OUTPATIENT MEDICAL SERVICES AND SUPPLIES |
| Durable Medical Equipment |
5% |
10% |
20% |
| Infusion Therapy |
$0 |
$0 |
20% |
| Prosthetic Devices |
5% |
20% |
20% |
| Diabetes Self-Monitoring Training and Supplies |
$0 |
$0 |
20% |
| Diagnostic Tests, X-Rays and Lab Services |
$0 |
$0 |
20% |
| PREVENTIVE SERVICES |
| Bone Mass Measurement |
$0 |
$0 |
20% |
| Colorectal Screening Exams |
$0 (1st exam), $5 for additional exams; unlimited |
$0 (1st exam), $5 for additional exams; unlimited |
20% |
Immunizations
(Flu and pneumonia) |
$0 |
| Mammograms |
$0 (1st exam), $5 for additional exams; unlimited |
$0 (1st exam), $5 for additional exams; unlimited |
20% |
| Pap Smears and Pelvic Exams |
$0 (1st exam), $5 for additional exams; unlimited |
$0 (1st exam), $5 for additional exams; unlimited |
20% |
| Prostate Cancer Screening Exams |
$0 (1st exam), $5 for additional exams; unlimited |
$0 (1st exam), $5 for additional exams; unlimited |
20% |
| Routine Physical Exams |
$0 |
Not covered |
Not covered |
| TRANSPORTATION |
| Transportation |
$5/trip, up to 12 one-way trips/year |
Not covered |
| ADDITIONAL BENEFITS |
| Dental Services |
$0 for selected preventive dental services including oral exam, cleaning and dental X-rays. $50 deductible for comprehensive services.
(Annual max. of $1,000 applies) |
| Hearing Services |
$10 for each diagnostic hearing exam |
20% for each diagnostic hearing exam |
Discounts on routine hearing exams and hearing aids |
| Vision Services |
$15 for routine eye exam (1 per year); $0 for 1 pair of glasses or contact lenses per year |
Routine eye exams and glasses not covered |
| Health Club Membership |
$0 for health club membership
(including fitness classes) |
Not covered |
| Health/Wellness Education |
Nutritional training, smoking cessation, newsletter, disease management, nurseline |
Not covered |
| PHARMACY COVERAGE (PART D) |
| Generic Drugs |
$0 for a 30-day supply
$0 for a 90-day supply (retail or mail order) |
| Preferred Brand-Name Drugs |
$20 for a 30-day supply
$40 for a 90-day supply (retail or mail order) |
| Non-Preferred Brand-Name Drugs |
$40 for a 30-day supply
$80 for a 90-day supply (retail or mail order)
|
| Specialty Drugs |
20% for a 30-day supply
20% for a 90-day supply (retail or mail order) |
Please note:
This grid is merely an overview and should not be used as a replacement for the Summary of Benefits or Evidence of Coverage. |
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