2021 紅藍卡計劃-立即比價 (第一保健/安泰/藍十字藍盾/Humana/聯合牛津/維康)

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Coverage Highlights

Star Rating

Annual In-Network Deductible$1000 for in-network and out-of-network combined

Out-of-Pocket Maximum$7550 for services you receive from in-network providers. $11300 for services you receive from any provider.

Office Visit for Primary DoctorIn-network: $10 copay
Out-of-network: $50 copay

Office Visit for SpecialistIn-network: $45 copay
Out-of-network: $60 copay

Inpatient Hospital CoverageInpatient hospital-acute:
In-network:
Our plan covers an unlimited number of days for an inpatient hospital stay.
Copayment amount for the medicare-covered stay: $850 copay
Out-of-network:
Our plan covers up to 90 days in an inpatient hospital stay.
$500 copay per day for days 1 through 20
$0 copay per day for days 21 through 90
Inpatient hospital psychiatric:
Copayment amount for the medicare-covered stay: $1871 copay

Prescription Drug Deductible$250
Applies to Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty Tier

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$15.00 copay

Tier 2: Generic$20.00 copay

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug$100.00 copay (after deductible)

Tier 5: Specialty Tier28% coinsurance (after deductible)

Other Coverage Highlights

聽覺 Services聽覺 exams:
Routine hearing exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: $60 copay
Fitting/evaluation for hearing aid (for up to 1 every year):
In-network: $0 copay
Out-of-network: $60 copay
聽覺 aids:
聽覺 aids (all types) (for up to 2 every year):
In-network: $0 copay
Out-of-network: $0 copay
Our plan pays up to $1250 every year for hearing aids. The maximum plan benefit coverage amount applies to both in-network and out-of-network services. The maximum plan benefit coverage amount applies Per ear.

眼科 ServicesEye exams:
Routine eye exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: $60 copay
Other service:
In-network: $45 copay
Out-of-network: $60 copay
Medicare-covered glaucoma screening:
In-network: $0 copay
Out-of-network: 30% coinsurance

健身In-network: $0 copay
Out-of-network: $0 copay

SilverSneakers健身運動項目Yes Find participating gyms

網上看診$0-$65 copay, depending on the service[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$7550 for services you receive from in-network providers. $11300 for services you receive from any provider.

Office Visit for Primary DoctorIn-network: $0 copay
Out-of-network: $25 copay

Office Visit for SpecialistIn-network: $45 copay
Out-of-network: $55 copay

Inpatient Hospital CoverageInpatient hospital-acute:
In-network:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$395 copay per day for days 1 through 5
$0 copay per day for days 6 through 90
You pay nothing per day for days 91 and beyond
Out-of-network:
Coinsurance percentage for OON inpatient hospital-acute stay: 50% coinsurance
Inpatient hospital psychiatric:
In-network:
Copayment amount for the medicare-covered stay: $1871 copay
Out-of-network:
Coinsurance percentage for OON inpatient psychiatric hospital stay: 50% coinsurance

Other Coverage Highlights

牙科 ServicesOral exams:
In-network: $0 copay
Out-of-network: $0 copay
Prophylaxis (cleaning):
In-network: $0 copay
Out-of-network: $0 copay
Fluoride treatment:
In-network: $0 copay
Out-of-network: $0 copay
牙科 x-rays:
In-network: $0 copay
Out-of-network: $0 copay
Non-routine services:
In-network: $0 copay
Out-of-network: 50% coinsurance or $0 copay, depending on the service
Diagnostic services:
In-network: $0 copay
Out-of-network: 50% coinsurance or $0 copay, depending on the service
Restorative services:
In-network: $0 copay
Out-of-network: 50% coinsurance or $0 copay, depending on the service
Endodontics:
In-network: $0 copay
Out-of-network: 50% coinsurance or $0 copay, depending on the service
Periodontics:
In-network: $0 copay
Out-of-network: 50% coinsurance or $0 copay, depending on the service
Extractions:
In-network: $0 copay
Out-of-network: 50% coinsurance or $0 copay, depending on the service
Prosthodontics, other oral/maxillofacial surgery, other services:
In-network: $0 copay
Out-of-network: 50% coinsurance or $0 copay, depending on the service
Our plan reimburses you up to $300 every year for dental services shown above. The maximum plan benefit coverage amount applies to both in-network and out-of-network services.

聽覺 Services聽覺 exams:
Routine hearing exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: $55 copay
Fitting/evaluation for hearing aid (for up to 1 every year):
In-network: $0 copay
Out-of-network: $55 copay
聽覺 aids:
聽覺 aids (all types) (for up to 2 every year):
In-network: $0 copay
Out-of-network: $0 copay
Our plan pays up to $1250 every year for hearing aids. The maximum plan benefit coverage amount applies to both in-network and out-of-network services. The maximum plan benefit coverage amount applies Per ear.

眼科 ServicesEye exams:
Routine eye exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: $55 copay
Other service:
In-network: $45 copay
Out-of-network: $55 copay
Eyewear:
Contact lenses:
In-network: $0 copay
Out-of-network: 50% coinsurance or $0 copay, depending on the service
Eyeglasses (lenses and frames):
In-network: $0 copay
Out-of-network: 50% coinsurance or $0 copay, depending on the service
Eyeglass lenses:
In-network: $0 copay
Out-of-network: 50% coinsurance or $0 copay, depending on the service
Eyeglass frames:
In-network: $0 copay
Out-of-network: 50% coinsurance or $0 copay, depending on the service
Upgrades:
In-network: $0 copay
Out-of-network: 50% coinsurance or $0 copay, depending on the service
Our plan reimburses you up to $150 every year for all eyewear.The maximum plan benefit coverage amount applies to both in-network and out-of-network services.
Medicare-covered glaucoma screening:
In-network: $0 copay
Out-of-network: 50% coinsurance

健身In-network: $0 copay
Out-of-network: 0% coinsurance

SilverSneakers健身運動項目Yes Find participating gyms

網上看診$0-$65 copay, depending on the service[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$7550 for services you receive from in-network providers. $11300 for services you receive from any provider.

Office Visit for Primary DoctorIn-network: $10 copay
Out-of-network: $50 copay

Office Visit for SpecialistIn-network: $45 copay
Out-of-network: $60 copay

Inpatient Hospital CoverageInpatient hospital-acute:
In-network:
Our plan covers an unlimited number of days for an inpatient hospital stay.
Copayment amount for the medicare-covered stay: $850 copay
Out-of-network:
Our plan covers up to 90 days in an inpatient hospital stay.
$500 copay per day for days 1 through 20
$0 copay per day for days 21 through 90
Inpatient hospital psychiatric:
Copayment amount for the medicare-covered stay: $1871 copay

Prescription Drug Deductible$250
Applies to Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty Tier

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$15.00 copay

Tier 2: Generic$20.00 copay

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug$100.00 copay (after deductible)

Tier 5: Specialty Tier28% coinsurance (after deductible)

Other Coverage Highlights

聽覺 Services聽覺 exams:
Routine hearing exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: $60 copay
Fitting/evaluation for hearing aid (for up to 1 every year):
In-network: $0 copay
Out-of-network: $60 copay
聽覺 aids:
聽覺 aids (all types) (for up to 2 every year):
In-network: $0 copay
Out-of-network: $0 copay
Our plan pays up to $1250 every year for hearing aids. The maximum plan benefit coverage amount applies to both in-network and out-of-network services. The maximum plan benefit coverage amount applies Per ear.

眼科 ServicesEye exams:
Routine eye exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: $60 copay
Other service:
In-network: $45 copay
Out-of-network: $60 copay
Eyewear:
Contact lenses:
In-network: $0 copay
Out-of-network: $0 copay or 30% coinsurance, depending on the service
Eyeglasses (lenses and frames):
In-network: $0 copay
Out-of-network: $0 copay or 30% coinsurance, depending on the service
Eyeglass lenses:
In-network: $0 copay
Out-of-network: $0 copay or 30% coinsurance, depending on the service
Eyeglass frames:
In-network: $0 copay
Out-of-network: $0 copay or 30% coinsurance, depending on the service
Upgrades:
In-network: $0 copay
Out-of-network: $0 copay or 30% coinsurance, depending on the service
Our plan reimburses you up to $150 every year for all eyewear.The maximum plan benefit coverage amount applies to both in-network and out-of-network services.
Medicare-covered glaucoma screening:
In-network: $0 copay
Out-of-network: 30% coinsurance

健身In-network: $0 copay
Out-of-network: $0 copay

SilverSneakers健身運動項目Yes Find participating gyms

網上看診$0-$65 copay, depending on the service

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[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network Deductible$1000 for in-network and out-of-network combined

Out-of-Pocket Maximum$7550 for services you receive from in-network providers. $11300 for services you receive from any provider.

Office Visit for Primary DoctorIn-network: $10 copay
Out-of-network: $50 copay

Office Visit for SpecialistIn-network: $45 copay
Out-of-network: $60 copay

Inpatient Hospital CoverageInpatient hospital-acute:
In-network:
Our plan covers an unlimited number of days for an inpatient hospital stay.
Copayment amount for the medicare-covered stay: $850 copay
Out-of-network:
Our plan covers up to 90 days in an inpatient hospital stay.
$500 copay per day for days 1 through 20
$0 copay per day for days 21 through 90
Inpatient hospital psychiatric:
Copayment amount for the medicare-covered stay: $1871 copay

Prescription Drug Deductible$300
Applies to Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty Tier

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$15.00 copay

Tier 2: Generic$20.00 copay

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug$100.00 copay (after deductible)

Tier 5: Specialty Tier27% coinsurance (after deductible)

Other Coverage Highlights

牙科 ServicesOral exams:
In-network: $0 copay
Out-of-network: $0 copay
Prophylaxis (cleaning):
In-network: $0 copay
Out-of-network: $0 copay
Fluoride treatment:
In-network: $0 copay
Out-of-network: $0 copay
牙科 x-rays:
In-network: $0 copay
Out-of-network: $0 copay
Non-routine services:
In-network: $0 copay
Out-of-network: $0-$60 copay, depending on the service
Diagnostic services:
In-network: $0 copay
Out-of-network: $0-$60 copay, depending on the service
Restorative services:
In-network: $0 copay
Out-of-network: $0-$60 copay, depending on the service
Endodontics:
In-network: $0 copay
Out-of-network: $0-$60 copay, depending on the service
Periodontics:
In-network: $0 copay
Out-of-network: $0-$60 copay, depending on the service
Extractions:
In-network: $0 copay
Out-of-network: $0-$60 copay, depending on the service
Prosthodontics, other oral/maxillofacial surgery, other services:
In-network: $0 copay
Out-of-network: $0-$60 copay, depending on the service
Our plan reimburses you up to $250 every year for dental services shown above. The maximum plan benefit coverage amount applies to both in-network and out-of-network services.

聽覺 Services聽覺 exams:
Routine hearing exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: $60 copay
Fitting/evaluation for hearing aid (for up to 1 every year):
In-network: $0 copay
Out-of-network: $60 copay
聽覺 aids:
聽覺 aids (all types) (for up to 2 every year):
In-network: $0 copay
Out-of-network: $0 copay
Our plan pays up to $1250 every year for hearing aids. The maximum plan benefit coverage amount applies to both in-network and out-of-network services. The maximum plan benefit coverage amount applies Per ear.

眼科 ServicesEye exams:
Routine eye exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: $60 copay
Other service:
In-network: $45 copay
Out-of-network: $60 copay
Eyewear:
Contact lenses:
In-network: $0 copay
Out-of-network: $0 copay or 30% coinsurance, depending on the service
Eyeglasses (lenses and frames):
In-network: $0 copay
Out-of-network: $0 copay or 30% coinsurance, depending on the service
Eyeglass lenses:
In-network: $0 copay
Out-of-network: $0 copay or 30% coinsurance, depending on the service
Eyeglass frames:
In-network: $0 copay
Out-of-network: $0 copay or 30% coinsurance, depending on the service
Upgrades:
In-network: $0 copay
Out-of-network: $0 copay or 30% coinsurance, depending on the service
Our plan reimburses you up to $150 every year for all eyewear.The maximum plan benefit coverage amount applies to both in-network and out-of-network services.
Medicare-covered glaucoma screening:
In-network: $0 copay
Out-of-network: 30% coinsurance

健身In-network: $0 copay
Out-of-network: $0 copay

SilverSneakers健身運動項目Yes Find participating gyms

網上看診$0-$65 copay, depending on the service

[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network Deductible$500

Out-of-Pocket Maximum$7550 for services you receive from in-network providers.

Office Visit for Primary Doctor$20 copay

Office Visit for Specialist$50 copay

Inpatient Hospital CoverageInpatient hospital-acute:
Our plan covers an unlimited number of days for an inpatient hospital stay.
Copayment amount for the medicare-covered stay: $795 copay
Inpatient hospital psychiatric:
Copayment amount for the medicare-covered stay: $1871 copay

Prescription Drug Deductible$300
Applies to Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty Tier

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$15.00 copay

Tier 2: Generic$20.00 copay

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug$100.00 copay (after deductible)

Tier 5: Specialty Tier27% coinsurance (after deductible)

Other Coverage Highlights

牙科 ServicesOral exams (for up to 2 every year): $0 copay
Prophylaxis (cleaning) (for up to 2 every year): $0 copay
牙科 x-rays (for up to 1): $0 copay

聽覺 Services聽覺 exams:
Routine hearing exams (for up to 1 every year): $0 copay
Fitting/evaluation for hearing aid (for up to 1 every year): $0 copay
聽覺 aids:
聽覺 aids (all types) (for up to 2 every year): $0 copay
Our plan pays up to $1250 every year for hearing aids. The maximum plan benefit coverage amount applies Per ear.

眼科 ServicesEye exams:
Routine eye exams (for up to 1 every year): $0 copay
Other service: $45 copay
Eyewear:
Contact lenses: $0 copay
Eyeglasses (lenses and frames): $0 copay
Eyeglass lenses: $0 copay
Eyeglass frames: $0 copay
Upgrades: $0 copay
Our plan reimburses you up to $200 every year for all eyewear.
Medicare-covered glaucoma screening: $0 copay

健身$0 copay

SilverSneakers健身運動項目Yes Find participating gyms

網上看診$0-$65 copay, depending on the service[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$7550 for services you receive from in-network providers. $11300 for services you receive from any provider.

Office Visit for Primary DoctorIn-network: $15 copay
Out-of-network: $50 copay

Office Visit for SpecialistIn-network: $45 copay
Out-of-network: $60 copay

Inpatient Hospital CoverageInpatient hospital-acute:
In-network:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$400 copay per day for days 1 through 5
$0 copay per day for days 6 through 90
You pay nothing per day for days 91 and beyond
Out-of-network:
Our plan covers up to 90 days in an inpatient hospital stay.
$500 copay per day for days 1 through 20
$0 copay per day for days 21 through 90
Inpatient hospital psychiatric:
Copayment amount for the medicare-covered stay: $1871 copay

Prescription Drug Deductible$200
Applies to Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty Tier

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$15.00 copay

Tier 2: Generic$20.00 copay

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug$100.00 copay (after deductible)

Tier 5: Specialty Tier29% coinsurance (after deductible)

Other Coverage Highlights

牙科 ServicesOral exams:
In-network: $0 copay
Out-of-network: $0 copay
Prophylaxis (cleaning):
In-network: $0 copay
Out-of-network: $0 copay
Fluoride treatment:
In-network: $0 copay
Out-of-network: $0 copay
牙科 x-rays:
In-network: $0 copay
Out-of-network: $0 copay
Non-routine services:
In-network: $0 copay
Out-of-network: $0-$60 copay, depending on the service
Diagnostic services:
In-network: $0 copay
Out-of-network: $0-$60 copay, depending on the service
Restorative services:
In-network: $0 copay
Out-of-network: $0-$60 copay, depending on the service
Endodontics:
In-network: $0 copay
Out-of-network: $0-$60 copay, depending on the service
Periodontics:
In-network: $0 copay
Out-of-network: $0-$60 copay, depending on the service
Extractions:
In-network: $0 copay
Out-of-network: $0-$60 copay, depending on the service
Prosthodontics, other oral/maxillofacial surgery, other services:
In-network: $0 copay
Out-of-network: $0-$60 copay, depending on the service
Our plan reimburses you up to $350 every year for dental services shown above. The maximum plan benefit coverage amount applies to both in-network and out-of-network services.

聽覺 Services聽覺 exams:
Routine hearing exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: $60 copay
Fitting/evaluation for hearing aid (for up to 1 every year):
In-network: $0 copay
Out-of-network: $60 copay
聽覺 aids:
聽覺 aids (all types) (for up to 2 every year):
In-network: $0 copay
Out-of-network: $0 copay
Our plan pays up to $1250 every year for hearing aids. The maximum plan benefit coverage amount applies to both in-network and out-of-network services. The maximum plan benefit coverage amount applies Per ear.

眼科 ServicesEye exams:
Routine eye exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: $60 copay
Other service:
In-network: $45 copay
Out-of-network: $60 copay
Eyewear:
Contact lenses:
In-network: $0 copay
Out-of-network: $0 copay or 30% coinsurance, depending on the service
Eyeglasses (lenses and frames):
In-network: $0 copay
Out-of-network: $0 copay or 30% coinsurance, depending on the service
Eyeglass lenses:
In-network: $0 copay
Out-of-network: $0 copay or 30% coinsurance, depending on the service
Eyeglass frames:
In-network: $0 copay
Out-of-network: $0 copay or 30% coinsurance, depending on the service
Upgrades:
In-network: $0 copay
Out-of-network: $0 copay or 30% coinsurance, depending on the service
Our plan reimburses you up to $175 every year for all eyewear.The maximum plan benefit coverage amount applies to both in-network and out-of-network services.
Medicare-covered glaucoma screening:
In-network: $0 copay
Out-of-network: 30% coinsurance

健身In-network: $0 copay
Out-of-network: $0 copay

SilverSneakers健身運動項目Yes Find participating gyms

網上看診$0-$65 copay, depending on the service[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$7550 for services you receive from in-network providers.

Office Visit for Primary Doctor$10 copay

Office Visit for Specialist$45 copay

Inpatient Hospital CoverageInpatient hospital-acute:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$400 copay per day for days 1 through 5
$0 copay per day for days 6 through 90
You pay nothing per day for days 91 and beyond
Inpatient hospital psychiatric:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$370 copay per day for days 1 through 5
$0 copay per day for days 6 through 90
You pay nothing per day for days 91 and beyond

Prescription Drug Deductible$350
Applies to Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty Tier

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$8.00 copay

Tier 2: Generic$20.00 copay

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug$99.00 copay (after deductible)

Tier 5: Specialty Tier26% coinsurance (after deductible)

Tier 6: Select Care Drugs$0.00 copay

Other Coverage Highlights

眼科 ServicesEye exams:
Routine eye exams (for up to 1 every year): $0 copay
Eyewear:
Contact lenses: $0 copay
Eyeglasses (lenses and frames): $0 copay
Eyeglass lenses: $0 copay
Eyeglass frames: $0 copay
Our plan pays up to $100 every year for all eyewear.
For Medicare-covered benefits see attached Summary of Benefits

健身$0 copay

SilverSneakers健身運動項目Yes Find participating gyms

非處方藥福利$0 copay. Up to $27 every three months

網上看診$0 copay[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$6900 for services you receive from in-network providers.

Office Visit for Primary Doctor$0 copay

Office Visit for Specialist$40 copay

Inpatient Hospital CoverageInpatient hospital-acute:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$375 copay per day for days 1 through 5
$0 copay per day for days 6 through 90
You pay nothing per day for days 91 and beyond
Inpatient hospital psychiatric:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$350 copay per day for days 1 through 5
$0 copay per day for days 6 through 90
You pay nothing per day for days 91 and beyond

Prescription Drug Deductible$350
Applies to Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty Tier

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$8.00 copay

Tier 2: Generic$20.00 copay

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug$99.00 copay (after deductible)

Tier 5: Specialty Tier26% coinsurance (after deductible)

Tier 6: Select Care Drugs$0.00 copay

Other Coverage Highlights

牙科 Services Oral exams (for up to 2 every year): $0 copay
Prophylaxis (cleaning) (for up to 2 every year): $0 copay
牙科 x-rays (for up to 1 every year): $0 copay
Our plan pays up to $1000 every year for dental services shown above.
For Medicare-covered benefits see attached Summary of Benefits

聽覺 Services聽覺 exams:
Routine hearing exams (for up to 1 every year): $0 copay
Fitting/evaluation for hearing aid (for up to 1 every year): $0 copay
聽覺 aids:
聽覺 aids (all types): $0 copay
Our plan pays up to $1500 every year for hearing aids. The maximum plan benefit coverage amount applies for both ears combined.
For Medicare-covered benefits see attached Summary of Benefits

眼科 ServicesEye exams:
Routine eye exams (for up to 1 every year): $0 copay
Eyewear:
Contact lenses: $0 copay
Eyeglasses (lenses and frames): $0 copay
Eyeglass lenses: $0 copay
Eyeglass frames: $0 copay
Our plan pays up to $150 every year for all eyewear.
For Medicare-covered benefits see attached Summary of Benefits

健身$0 copay

SilverSneakers健身運動項目Yes Find participating gyms

非處方藥福利$0 copay. Up to $35 every three months

網上看診$0 copay[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$6700 for services you receive from in-network providers.

Office Visit for Primary Doctor$10 copay

Office Visit for Specialist$30 copay

Inpatient Hospital CoverageInpatient hospital-acute:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$350 copay per day for days 1 through 5
$0 copay per day for days 6 through 90
You pay nothing per day for days 91 and beyond
Inpatient hospital psychiatric:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$415 copay per day for days 1 through 4
$0 copay per day for days 5 through 90
You pay nothing per day for days 91 and beyond

Other Coverage Highlights

眼科 ServicesEye exams:
Routine eye exams (for up to 1 every year): $0 copay
For Medicare-covered benefits see attached Summary of Benefits

健身$0 copay

SilverSneakers健身運動項目Yes Find participating gyms

非處方藥福利$0 copay. Up to $64 every three months

網上看診$0 copay[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$7550 for services you receive from in-network providers.

Office Visit for Primary Doctor$20 copay

Office Visit for Specialist$50 copay

Inpatient Hospital CoverageInpatient hospital-acute:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$400 copay per day for days 1 through 5
$0 copay per day for days 6 through 90
You pay nothing per day for days 91 and beyond
Inpatient hospital psychiatric:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$465 copay per day for days 1 through 4
$0 copay per day for days 5 through 90
You pay nothing per day for days 91 and beyond

Other Coverage Highlights

牙科 ServicesOral exams (for up to 2 every year): $0 copay
Prophylaxis (cleaning) (for up to 2 every year): $0 copay
牙科 x-rays (for up to 1 every year): $0 copay
Our plan pays up to $125 every three months for dental services shown above.
For Medicare-covered benefits see attached Summary of Benefits

眼科 ServicesEye exams:
Routine eye exams (for up to 1 every year): $0 copay
For Medicare-covered benefits see attached Summary of Benefits

健身$0 copay

SilverSneakers健身運動項目Yes Find participating gyms

網上看診$0 copay[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$7550 for services you receive from in-network providers.

Office Visit for Primary Doctor$20 copay

Office Visit for Specialist$50 copay

Inpatient Hospital CoverageInpatient hospital-acute:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$500 copay per day for days 1 through 4
$0 copay per day for days 5 through 90
You pay nothing per day for days 91 and beyond
Inpatient hospital psychiatric:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$465 copay per day for days 1 through 4
$0 copay per day for days 5 through 90
You pay nothing per day for days 91 and beyond

Prescription Drug Deductible$350
Applies to Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty Tier

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$0.00 copay

Tier 2: Generic$20.00 copay

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug$99.00 copay (after deductible)

Tier 5: Specialty Tier26% coinsurance (after deductible)

Other Coverage Highlights

眼科 ServicesEye exams:
Routine eye exams (for up to 1 every year): $0 copay
For Medicare-covered benefits see attached Summary of Benefits

健身$0 copay

SilverSneakers健身運動項目Yes Find participating gyms

網上看診$0 copay[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$5900 for services you receive from in-network providers.

Office Visit for Primary Doctor$5 copay

Office Visit for Specialist$25 copay

Inpatient Hospital CoverageInpatient hospital-acute:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$300 copay per day for days 1 through 5
$0 copay per day for days 6 through 90
You pay nothing per day for days 91 and beyond
Inpatient hospital psychiatric:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$395 copay per day for days 1 through 4
$0 copay per day for days 5 through 90
You pay nothing per day for days 91 and beyond

Prescription Drug Deductible$445
Applies to Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty Tier

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$0.00 copay

Tier 2: Generic$15.00 copay

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug$100.00 copay (after deductible)

Tier 5: Specialty Tier25% coinsurance (after deductible)

Tier 6: Select Care Drugs$0.00 copay

Other Coverage Highlights

牙科 ServicesOral exams (for up to 2 every year): $0 copay
Prophylaxis (cleaning) (for up to 2 every year): $0 copay
牙科 x-rays (for up to 1 every year): $0 copay
Our plan pays up to $375 every three months for dental services shown above.
For Medicare-covered benefits see attached Summary of Benefits

聽覺 Services聽覺 exams:
Routine hearing exams (for up to 1 every year): $0 copay
Fitting/evaluation for hearing aid (for up to 1 every year): $0 copay
聽覺 aids:
聽覺 aids (all types): $0 copay
Our plan pays up to $2000 every year for hearing aids. The maximum plan benefit coverage amount applies for both ears combined.
For Medicare-covered benefits see attached Summary of Benefits

眼科 ServicesEye exams:
Routine eye exams (for up to 1 every year): $0 copay
Eyewear:
Contact lenses: $0 copay
Eyeglasses (lenses and frames): $0 copay
Eyeglass lenses: $0 copay
Eyeglass frames: $0 copay
Our plan pays up to $150 every year for all eyewear.
For Medicare-covered benefits see attached Summary of Benefits

健身$0 copay

SilverSneakers健身運動項目Yes Find participating gyms

非處方藥福利$0 copay. Up to $112 every three months

免費接送$0 copay. 12, one-way, routine transportation services every year.

網上看診$0 copay[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$7550 for services you receive from in-network providers.

Office Visit for Primary Doctor$0 copay

Office Visit for Specialist$0 copay

Inpatient Hospital Coverage$0.00 copay per stay.
Our plan covers 90 days for an inpatient hospital stay.

Prescription Drug Deductible$445
Applies to Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty Tier

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$0.00 copay

Tier 2: Generic$0.00 – $3.70 copay

Tier 3: Preferred Brand$0.00 – $9.20 copay

Tier 4: Non-Preferred Drug$0.00 – $9.20 copay

Tier 5: Specialty Tier$0.00 – $9.20 copay for One-month supply

Tier 6: Select Care Drugs$0 copay

Other Coverage Highlights

健身Yes

SilverSneakers健身運動項目Yes Find participating gyms

非處方藥福利This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $158 every quarter. Unused OTC amounts do roll over to the next quarter. Unused OTC amounts do not roll over to the next calendar year.

網上看診Yes[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$7550 for services you receive from in-network providers.

Office Visit for Primary Doctor$0 copay

Office Visit for Specialist$0 copay

Inpatient Hospital Coverage$0.00 copay per stay.
Our plan covers 90 days for an inpatient hospital stay.

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$0.00 copay

Tier 2: Generic$0.00 – $3.70 copay

Tier 3: Preferred Brand$0.00 – $9.20 copay

Tier 4: Non-Preferred Drug$0.00 – $9.20 copay

Tier 5: Specialty Tier$0.00 – $9.20 copay for One-month supply

Tier 6: Select Care Drugs$0 copay

Other Coverage Highlights

牙科 ServicesOral exams (for up to 2 every year): $0 copay
Prophylaxis (cleaning) (for up to 2 every year): $0 copay
牙科 x-rays (for up to 1 every year): $0 copay
Our plan pays up to $575 every three months for dental services shown above.
For Medicare-covered benefits see attached Summary of Benefits

聽覺 Services聽覺 exams:
Routine hearing exams (for up to 1 every year): $0 copay
Fitting/evaluation for hearing aid (for up to 1 every year): $0 copay
聽覺 aids:
聽覺 aids (all types): $0 copay
Our plan pays up to $3000 every year for hearing aids. The maximum plan benefit coverage amount applies for both ears combined.
For Medicare-covered benefits see attached Summary of Benefits

眼科 ServicesEye exams:
Routine eye exams (for up to 1 every year): $0 copay
Eyewear:
Contact lenses: $0 copay
Eyeglasses (lenses and frames): $0 copay
Eyeglass lenses: $0 copay
Eyeglass frames: $0 copay
Our plan pays up to $300 every year for all eyewear.
For Medicare-covered benefits see attached Summary of Benefits

健身Yes

SilverSneakers健身運動項目Yes Find participating gyms

非處方藥福利This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $300 every quarter. Unused OTC amounts do roll over to the next quarter. Unused OTC amounts do not roll over to the next calendar year.

免費接送$0 copay. 12, one-way, routine transportation services every year.

網上看診Yes[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$7550 for services you receive from in-network providers.

Office Visit for Primary Doctor$0 copay

Office Visit for Specialist$0 copay

Inpatient Hospital Coverage$0 copay per stay.
Our plan covers 90 days for an inpatient hospital stay.

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$0.00 copay

Tier 2: Generic$0.00 – $3.70 copay

Tier 3: Preferred Brand$0.00 – $9.20 copay

Tier 4: Non-Preferred Drug$0.00 – $9.20 copay

Tier 5: Specialty Tier$0.00 – $9.20 copay for One-month supply

Tier 6: Select Care Drugs$0 copay

Other Coverage Highlights

健身Yes

SilverSneakers健身運動項目Yes Find participating gyms

非處方藥福利This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $52 every quarter. Unused OTC amounts do roll over to the next quarter. Unused OTC amounts do not roll over to the next calendar year.

網上看診Yes[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$7550 for services you receive from in-network providers.

Office Visit for Primary Doctor$0 copay

Office Visit for Specialist$0 copay

Inpatient Hospital Coverage$0 copay per stay.
Our plan covers 90 days for an inpatient hospital stay.

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$0.00 copay

Tier 2: Generic$0.00 – $3.70 copay

Tier 3: Preferred Brand$0.00 – $9.20 copay

Tier 4: Non-Preferred Drug$0.00 – $9.20 copay

Tier 5: Specialty Tier$0.00 – $9.20 copay for One-month supply

Tier 6: Select Care Drugs$0 copay

Other Coverage Highlights

牙科 ServicesOral exams (for up to 2 every year): $0 copay
Prophylaxis (cleaning) (for up to 2 every year): $0 copay
牙科 x-rays (for up to 1 every year): $0 copay
Our plan pays up to $450 every three months for dental services shown above.
For Medicare-covered benefits see attached Summary of Benefits

聽覺 Services聽覺 exams:
Routine hearing exams (for up to 1 every year): $0 copay
Fitting/evaluation for hearing aid (for up to 1 every year): $0 copay
聽覺 aids:
聽覺 aids (all types): $0 copay
Our plan pays up to $1500 every year for hearing aids. The maximum plan benefit coverage amount applies for both ears combined.
For Medicare-covered benefits see attached Summary of Benefits

眼科 ServicesEye exams:
Routine eye exams (for up to 1 every year): $0 copay
Eyewear:
Contact lenses: $0 copay
Eyeglasses (lenses and frames): $0 copay
Eyeglass lenses: $0 copay
Eyeglass frames: $0 copay
Our plan pays up to $300 every year for all eyewear.
For Medicare-covered benefits see attached Summary of Benefits

健身Yes

SilverSneakers健身運動項目Yes Find participating gyms

非處方藥福利This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $210 every quarter. Unused OTC amounts do roll over to the next quarter. Unused OTC amounts do not roll over to the next calendar year.

網上看診Yes[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$4500 for services you receive from in-network providers. $10000 for services you receive from any provider.

Office Visit for Primary DoctorIn-network: $0 copay
Out-of-network: 30% coinsurance

Office Visit for SpecialistIn-network: $40 copay
Out-of-network: 30% coinsurance

Inpatient Hospital CoverageInpatient hospital-acute:
In-network:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$350 copay per day for days 1 through 5
$0 copay per day for days 6 through 90
$0 copay per day for days 91 and beyond
Out-of-network:
Coinsurance percentage for OON inpatient hospital-acute stay: 30% coinsurance
Inpatient hospital psychiatric:
In-network:
Our plan covers up to 90 days in an inpatient hospital stay.
$324 copay per day for days 1 through 5
$0 copay per day for days 6 through 90
Out-of-network:
Coinsurance percentage for OON inpatient psychiatric hospital stay: 30% coinsurance

Other Coverage Highlights

牙科 Services Eye exams:
Oral exams (for up to 3):
In-network: 0% coinsurance
Out-of-network: 50% coinsurance
Prophylaxis (cleaning) (for up to 2 every year):
In-network: 0% coinsurance
Out-of-network: 50% coinsurance
Fluoride treatment (for up to 2 every year):
In-network: 0% coinsurance
Out-of-network: 50% coinsurance
牙科 x-rays (for up to 3):
In-network: 0% coinsurance
Out-of-network: 50% coinsurance
Restorative services (for up to 2 every year):
In-network: 50% coinsurance
Out-of-network: 55%-75% coinsurance, depending on the service
Periodontics (for up to 5):
In-network: 70% coinsurance
Out-of-network: 55%-75% coinsurance, depending on the service
Extractions (for up to 2 every year):
In-network: 50% coinsurance
Out-of-network: 55%-75% coinsurance, depending on the service
Our plan pays up to $2000 every year for dental services shown above. The maximum plan benefit coverage amount applies to both in-network and out-of-network services.

聽覺 Services聽覺 exams:
Routine hearing exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: $0 copay or 30% coinsurance, depending on the service
Fitting/evaluation for hearing aid (for up to 1 every year):
In-network: $0 copay
Out-of-network: $0 copay or 30% coinsurance, depending on the service
聽覺 aids:
聽覺 aids (all types) (for up to 2 every year):
In-network: $399-$699 copay, depending on the service
Out-of-network: $399-$699 copay, depending on the service.

眼科 ServicesEye exams:
Routine eye exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: $0 copay or 30% coinsurance, depending on the service
Our plan pays up to $75 every year for eye exams. The maximum plan benefit coverage amount applies to both in-network and out-of-network services.
Eyewear:
Contact lenses (for up to 1 every year):
In-network: $0 copay
Out-of-network: $0 copay
Eyeglasses (lenses and frames) (for up to 1 every year):
In-network: $0 copay
Out-of-network: $0 copay
Our plan pays up to $200 every year for all eyewear.The maximum plan benefit coverage amount applies to both in-network and out-of-network services.
Medicare-covered glaucoma screening:
In-network: $0 copay
Out-of-network: 30% coinsurance

健身In-network: You pay nothing
Out-of-network: 50% coinsurance

SilverSneakers健身運動項目Yes Find participating gyms

非處方藥福利In-network: You pay nothing. Up to $50 every three months
Out-of-network: 50% coinsurance

免費接送In-network: $0 copay, 24 trips every year by Van or other forms of conveyances (one-way) to plan approved health-related location.
Out-of-network: 50% coinsurance

網上看診$0-$40 copay, depending on the service[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network Deductible$800

Out-of-Pocket Maximum$7550 for services you receive from in-network providers.

Office Visit for Primary Doctor$0 copay

Office Visit for Specialist$50 copay

Inpatient Hospital CoverageInpatient hospital-acute:
Our plan covers an unlimited number of days for an inpatient hospital stay.
Copayment amount for the medicare-covered stay: $700 copay
Inpatient hospital psychiatric:
Copayment amount for the medicare-covered stay: $700 copay

Prescription Drug Deductible$400
Applies to Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty Tier

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$10.00 copay

Tier 2: Generic$20.00 copay

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug$100.00 copay (after deductible)

Tier 5: Specialty Tier25% coinsurance (after deductible)

Other Coverage Highlights

聽覺 Services 聽覺 exams:
Routine hearing exams (for up to 1 every year): $0 copay
Fitting/evaluation for hearing aid (for up to 1 every year): $0 copay
聽覺 aids:
聽覺 aids (all types) (for up to 2 every year): $699-$999 copay, depending on the service

眼科 Services Eye exams:
Routine eye exams (for up to 1 every year): $0 copay
Eyewear:
Contact lenses (for up to 1 every year): $0 copay
Eyeglasses (lenses and frames) (for up to 1 every year): $0 copay
Our plan pays up to $100 every year for all eyewear.
Medicare-covered glaucoma screening: $0 copay

健身You pay nothing

SilverSneakers健身運動項目Yes Find participating gyms

網上看診$0-$50 copay, depending on the service[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible

Out-of-Pocket Maximum$7550 for services you receive from in-network providers.

Office Visit for Primary Doctor$0 copay

Office Visit for Specialist$45 copay

Inpatient Hospital CoverageInpatient hospital-acute:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$495 copay per day for days 1 through 4
$0 copay per day for days 5 through 90
$0 copay per day for days 91 and beyond
Inpatient hospital psychiatric:
Our plan covers up to 90 days in an inpatient hospital stay.
$465 copay per day for days 1 through 4
$0 copay per day for days 5 through 90

Prescription Drug Deductible$350
Applies to Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty Tier

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$10.00 copay

Tier 2: Generic$20.00 copay

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug$100.00 copay (after deductible)

Tier 5: Specialty Tier26% coinsurance (after deductible)

Other Coverage Highlights

牙科 Services
Oral exams (for up to 3): 0% coinsurance
Prophylaxis (cleaning) (for up to 2 every year): 0% coinsurance
牙科 x-rays (for up to 3): 0% coinsurance
Restorative services (for up to 3 every year): 50%-70% coinsurance, depending on the service
Extractions: 50% coinsurance
Prosthodontics, other oral/maxillofacial surgery, other services (for up to 4): 70% coinsurance
Our plan pays up to $2000 every year for dental services shown above.

聽覺 Services聽覺 exams:
Routine hearing exams (for up to 1 every year): $0 copay
Fitting/evaluation for hearing aid (for up to 1 every year): $0 copay
聽覺 aids:
聽覺 aids (all types) (for up to 2 every year): $699-$999 copay, depending on the service

眼科 Services Eye exams:
Routine eye exams (for up to 1 every year): $0 copay
Eyewear:
Contact lenses (for up to 1 every year): $0 copay
Eyeglasses (lenses and frames) (for up to 1 every year): $0 copay
Our plan pays up to $200 every year for all eyewear.
Medicare-covered glaucoma screening: $0 copay

健身You pay nothing

SilverSneakers健身運動項目Yes Find participating gyms

非處方藥福利You pay nothing. Up to $45 every three months

免費接送 $0 copay, 36 trips every year by Van or other forms of conveyances (one-way) to plan approved health-related location.

網上看診$0-$50 copay, depending on the service[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible

Out-of-Pocket Maximum$7200 for services you receive from in-network providers. $11000 for services you receive from any provider.

Office Visit for Primary DoctorIn-network: $0 copay
Out-of-network: $15 copay

Office Visit for SpecialistIn-network: $40 copay
Out-of-network: $50 copay

Inpatient Hospital CoverageInpatient hospital-acute:
In-network:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$350 copay per day for days 1 through 5
$0 copay per day for days 6 through 90
$0 copay per day for days 91 and beyond
Out-of-network:
Our plan covers up to 90 days in an inpatient hospital stay.
$500 copay per day for days 1 through 7
$0 copay per day for days 8 through 90
Inpatient hospital psychiatric:
In-network:
Our plan covers up to 90 days in an inpatient hospital stay.
$350 copay per day for days 1 through 5
$0 copay per day for days 6 through 90
Out-of-network:
Our plan covers up to 90 days in an inpatient hospital stay.
$500 copay per day for days 1 through 7
$0 copay per day for days 8 through 90

Prescription Drug Deductible$350
Applies to Tier 4: Non-Preferred Drug, Tier 5: Specialty Tier

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$10.00 copay

Tier 2: Generic$20.00 copay

Tier 3: Preferred Brand$47.00 copay

Tier 4: Non-Preferred Drug$100.00 copay (after deductible)

Tier 5: Specialty Tier26% coinsurance (after deductible)

Other Coverage Highlights

聽覺 Services聽覺 exams:
Routine hearing exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: $0-$50 copay, depending on the service
Fitting/evaluation for hearing aid (for up to 1 every year):
In-network: $0 copay
Out-of-network: $0-$50 copay, depending on the service
聽覺 aids:
聽覺 aids (all types) (for up to 2 every year):
In-network: $699-$999 copay, depending on the service
Out-of-network: $699-$999 copay, depending on the service

眼科 Services Eye exams:
Routine eye exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: $0-$50 copay, depending on the service
Our plan pays up to $75 every year for eye exams. The maximum plan benefit coverage amount applies to both in-network and out-of-network services.
Eyewear:
Contact lenses (for up to 1 every year):
In-network: $0 copay
Out-of-network: $0 copay
Eyeglasses (lenses and frames) (for up to 1 every year):
In-network: $0 copay
Out-of-network: $0 copay
Our plan pays up to $100 every year for all eyewear.The maximum plan benefit coverage amount applies to both in-network and out-of-network services.
Medicare-covered glaucoma screening:
In-network: $0 copay
Out-of-network: $50 copay

健身In-network: You pay nothing
Out-of-network: 50% coinsurance

SilverSneakers健身運動項目Yes Find participating gyms

網上看診$0-$40 copay, depending on the service[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible

Out-of-Pocket Maximum$6500 for services you receive from in-network providers.

Office Visit for Primary Doctor$0 copay

Office Visit for Specialist$40 copay

Inpatient Hospital CoverageInpatient hospital-acute:
Inpatient hospital-acute:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$325 copay per day for days 1 through 6
$0 copay per day for days 7 through 90
$0 copay per day for days 91 and beyond
Inpatient hospital psychiatric:
Our plan covers up to 90 days in an inpatient hospital stay.
$290 copay per day for days 1 through 6
$0 copay per day for days 7 through 90

Prescription Drug Deductible$200
Applies to Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty Tier

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$10.00 copay

Tier 2: Generic$20.00 copay

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug$100.00 copay (after deductible)

Tier 5: Specialty Tier29% coinsurance (after deductible)

Other Coverage Highlights

牙科 Services
Oral exams (for up to 3): 0% coinsurance
Prophylaxis (cleaning) (for up to 2 every year): 0% coinsurance
牙科 x-rays (for up to 3): 0% coinsurance
Restorative services (for up to 3 every year): 50%-70% coinsurance, depending on the service
Extractions: 50% coinsurance
Prosthodontics, other oral/maxillofacial surgery, other services (for up to 4): 70% coinsurance
Our plan pays up to $2000 every year for dental services shown above.

聽覺 Services 聽覺 exams:
Routine hearing exams (for up to 1 every year): $0 copay
Fitting/evaluation for hearing aid (for up to 1 every year): $0 copay
聽覺 aids:
聽覺 aids (all types) (for up to 2 every year): $399-$699 copay, depending on the service

眼科 Services Eye exams:
Routine eye exams (for up to 1 every year): $0 copay
Eyewear:
Contact lenses (for up to 1 every year): $0 copay
Eyeglasses (lenses and frames) (for up to 1 every year): $0 copay
Our plan pays up to $200 every year for all eyewear.
Medicare-covered glaucoma screening: $0 copay

健身You pay nothing

SilverSneakers健身運動項目Yes Find participating gyms

非處方藥福利 You pay nothing. Up to $45 every three months

免費接送$0 copay, 48 trips every year by Van or other forms of conveyances (one-way) to plan approved health-related location.

網上看診$0-$40 copay, depending on the service[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible

Out-of-Pocket MaximumThis plan does not have a maximum out-of-pocket responsibility

Office Visit for Primary Doctor$0 copay

Office Visit for Specialist$0 copay

Inpatient Hospital Coverage$0 copay

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic30-day supply:For generic drugs (including brand drugs treated as generic), either:$0 copay; or $1.30 copay; or $3.70 copay.For all other drugs, either:$0 copay; or $4 copay; or $9.20 copay.90-day supply:For generic drugs (including brand drugs treated as generic), either:$0 copay; or $1.30 copay; or $3.70 copay.For all other drugs, either:$0 copay; or $4 copay; or $9.20 copay.

Tier 2: Generic30-day supply:For generic drugs (including brand drugs treated as generic), either:$0 copay; or $1.30 copay; or $3.70 copay.For all other drugs, either:$0 copay; or $4 copay; or $9.20 copay.90-day supply:For generic drugs (including brand drugs treated as generic), either:$0 copay; or $1.30 copay; or $3.70 copay.For all other drugs, either:$0 copay; or $4 copay; or $9.20 copay.

Tier 3: Preferred Brand30-day supply:For generic drugs (including brand drugs treated as generic), either:$0 copay; or $1.30 copay; or $3.70 copay.For all other drugs, either:$0 copay; or $4 copay; or $9.20 copay.90-day supply:For generic drugs (including brand drugs treated as generic), either:$0 copay; or $1.30 copay; or $3.70 copay.For all other drugs, either:$0 copay; or $4 copay; or $9.20 copay.

Tier 4: Non-Preferred Drug30-day supply:For generic drugs (including brand drugs treated as generic), either:$0 copay; or $1.30 copay; or $3.70 copay.For all other drugs, either:$0 copay; or $4 copay; or $9.20 copay.90-day supply:For generic drugs (including brand drugs treated as generic), either:$0 copay; or $1.30 copay; or $3.70 copay.For all other drugs, either:$0 copay; or $4 copay; or $9.20 copay.

Tier 5: Specialty Tier30-day supply:For generic drugs (including brand drugs treated as generic), either:$0 copay; or $1.30 copay; or $3.70 copay.For all other drugs, either:$0 copay; or $4 copay; or $9.20 copay.90-day supply:For generic drugs (including brand drugs treated as generic), either:$0 copay; or $1.30 copay; or $3.70 copay.For all other drugs, either:$0 copay; or $4 copay; or $9.20 copay.

Other Coverage Highlights

牙科 Services Medicare-covered dental $0 copay
Routine dental In-network: DEN175
• $0 copayment for scaling and root planing (deep cleaning) up to 1per quadrant every 3 years.
• $0 copayment for comprehensive oral evaluation or periodontal exam up to 1 every 3 years.
• $0 copayment for complete dentures, partial dentures up to 1set(s) every 5 years.
• $0 copayment for panoramic film or diagnostic x-rays, recementation up to 1every 5 years.
• $0 copayment for bitewing x-rays up to 1set(s) per year.
• $0 copayment for adjustments to dentures, denture reline, intraoral x-rays, root canal up to 1per year.
• $0 copayment for amalgam and/or composite filling, crown, emergency treatment for pain, fluoride treatment, oral surgery, periodic oral exam and/or emergency diagnostic exam, prophylaxis (cleaning) up to 2 per year.
• $0 copayment for periodontal maintenance up to 4per year.
• $0 copayment for necessary anesthesia with covered service, simple or surgical extraction up to unlimited per year.
• $1000 maximum benefit coverage amount per year for preventive and comprehensive benefits

聽覺 Services Medicare-covered hearing $0 copay
Routine hearing In-network: HER814
• $0 copayment for fitting/evaluation, routine hearing exams up to 1per year.
• $1000 maximum benefit coverage amount for hearing aids (all types) up to 2 every 3 years.

眼科 Services Medicare-covered vision services $0 copay
Medicare-covered diabetic eye exam $0 copay
Medicare-covered glaucoma screening $0 copay
Medicare-covered eyewear (post-cataract) $0 copay
Routine vision In-Network VIS733
• $0 copayment for refraction, routine exam up to 1per year.
• $300 maximum benefit coverage amount per year for contact lenses or eyeglasses-lenses and frames, fitting for eyeglasses-lenses and frames.
• Eyeglasses include ultraviolet protection and scratch resistant coating.

健身SilverSneakers健身運動項目 ® fitness program: Basic fitness center membership including fitness classes.

SilverSneakers健身運動項目Yes Find participating gyms

非處方藥福利 $100 every month for approved over-the-counter items at participating retailers

免費接送$0 copay for up to 48 one-way trips to plan approved locations. Not to exceed 25 miles per trip. The member must contact transportation vendor to arrange transportation

網上看診$0 copay[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$6700 for services you receive from in-network providers.

Office Visit for Primary Doctor$20 copay

Office Visit for Specialist$40 copay

Inpatient Hospital CoverageInpatient hospital-acute:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$345 copay per day for days 1 through 5
$0 copay per day for days 6 through 90
$0 copay per day for days 91 and beyond
Inpatient hospital psychiatric:
Our plan covers up to 90 days in an inpatient hospital stay.
$345 copay per day for days 1 through 5
$0 copay per day for days 6 through 90

Other Coverage Highlights

牙科 Services Oral exams (for up to 2 every year): $0 copay
Prophylaxis (cleaning) (for up to 3 every year): $0 copay
Fluoride treatment (for up to 2 every year): $0 copay
牙科 x-rays (for up to 1 every three years): $0 copay

聽覺 Services 聽覺 exams:
Routine hearing exams (for up to 1 every year): $0 copay
聽覺 aids:
聽覺 aids (all types) (for up to 2 every two years): $375-$2075 copay, depending on the services

眼科 Services Eye exams:
Routine eye exams (for up to 1 every year): $0 copay
Eyewear:
Contact lenses: $0 copay
Eyeglasses (lenses and frames) (for up to 1 every two years): $0 copay
Our plan pays up to $100 every two years for all eyewear.
Medicare-covered glaucoma screening: $0 copay

健身$0 copay

網上看診$0 copay[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network Deductible$500

Out-of-Pocket Maximum$6700 for services you receive from in-network providers.

Office Visit for Primary Doctor$10 copay

Office Visit for Specialist$40 copay

Inpatient Hospital CoverageInpatient hospital-acute:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$345 copay per day for days 1 through 5
$0 copay per day for days 6 through 90
$0 copay per day for days 91 and beyond
Inpatient hospital psychiatric:
Our plan covers up to 90 days in an inpatient hospital stay.
$345 copay per day for days 1 through 5
$0 copay per day for days 6 through 90

Prescription Drug Deductible$295
Applies to Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty Tier

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$3.00 copay

$3.00 copayTier 2: Generic$12.00 copay

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug$100.00 copay (after deductible)

Tier 5: Specialty Tier27% coinsurance (after deductible)

Other Coverage Highlights

牙科 Services Oral exams (for up to 2 every year): $0 copay
Prophylaxis (cleaning) (for up to 3 every year): $0 copay
Fluoride treatment (for up to 2 every year): $0 copay
牙科 x-rays (for up to 1 every three years): $0 copay

聽覺 Services 聽覺 exams:
Routine hearing exams (for up to 1 every year): $0 copay
聽覺 aids:
聽覺 aids (all types) (for up to 2 every two years): $375-$2075 copay, depending on the services

眼科 Services Eye exams:
Routine eye exams (for up to 1 every year): $0 copay
Eyewear:
Contact lenses: $0 copay
Eyeglasses (lenses and frames) (for up to 1 every two years): $0 copay
Our plan pays up to $100 every two years for all eyewear.
Medicare-covered glaucoma screening: $0 copay

健身$0 copay

網上看診$0 copay[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Annual In-Network Deductible$1000

Out-of-Pocket Maximum$6700 for services you receive from in-network providers. $10000 for services you receive from any provider.

Office Visit for Primary DoctorIn-network: $0-$25 copay, depending on the services
Out-of-network: 50% coinsurance

Office Visit for SpecialistIn-network: $25-$50 copay, depending on the services
Out-of-network: 50% coinsurance

Inpatient Hospital CoverageInpatient hospital-acute:
In-network:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$360 copay per day for days 1 through 5
$0 copay per day for days 6 through 90
$0 copay per day for days 91 and beyond
Out-of-network:
Coinsurance percentage for OON inpatient hospital-acute stay: 50% coinsurance
Inpatient hospital psychiatric:
In-network:
Our plan covers up to 90 days in an inpatient hospital stay.
$360 copay per day for days 1 through 5
$0 copay per day for days 6 through 90
Out-of-network:
Coinsurance percentage for OON inpatient psychiatric hospital stay: 50% coinsurance

Prescription Drug Deductible$250
Applies to Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty Tie

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$3.00 copay

$3.00 copayTier 2: Generic$12.00 copay

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug$100.00 copay (after deductible)

Tier 5: Specialty Tier28% coinsurance (after deductible)

Other Coverage Highlights

牙科 Services Oral exams (for up to 2 every year):
In-network: $0 copay
Out-of-network: $0 copay
Prophylaxis (cleaning) (for up to 3 every year):
In-network: $0 copay
Out-of-network: $0 copay
Fluoride treatment (for up to 2 every year):
In-network: $0 copay
Out-of-network: $0 copay
牙科 x-rays (for up to 1 every three years):
In-network: $0 copay
Out-of-network: $0 copay

聽覺 Services 聽覺 exams:
Routine hearing exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: 50% coinsurance
聽覺 aids:
聽覺 aids (all types) (for up to 2 every two years):
In-network: $375-$2075 copay, depending on the services
Out-of-network: $375 copay

眼科 Services Eye exams:
Routine eye exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: 50% coinsurance
Eyewear:
Contact lenses:
In-network: $0 copay
Out-of-network: 50% coinsurance or $0 copay, depending on the services
Eyeglasses (lenses and frames) (for up to 1 every two years):
In-network: $0 copay
Out-of-network: 50% coinsurance or $0 copay, depending on the services
Our plan pays up to $300 every two years for all eyewear.The maximum plan benefit coverage amount applies to both in-network and out-of-network services.
Medicare-covered glaucoma screening:
In-network: $0 copay
Out-of-network: 50% coinsurance

健身In-network: $0 copay
Out-of-network: $0 copay

網上看診$0 copay[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$6700 for services you receive from in-network providers.

Office Visit for Primary Doctor$20 copay

Office Visit for Specialist$50 copay

Inpatient Hospital CoverageInpatient hospital-acute:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$390 copay per day for days 1 through 5
$0 copay per day for days 6 through 90
$0 copay per day for days 91 and beyond
Inpatient hospital psychiatric:
Our plan covers up to 90 days in an inpatient hospital stay.
$390 copay per day for days 1 through 4
$0 copay per day for days 5 through 90

Prescription Drug Deductible$395
Applies to Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty Tier

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$3.00 copay

Tier 2: Generic$12.00 copay

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug$100.00 copay (after deductible)

Tier 5: Specialty Tier28% coinsurance (after deductible)

Other Coverage Highlights

聽覺 Services 聽覺 exams:
Routine hearing exams (for up to 1 every year): $0 copay
聽覺 aids:
聽覺 aids (all types) (for up to 2 every two years): $375-$2075 copay, depending on the services

眼科 Services Eye exams:
Routine eye exams (for up to 1 every year): $0 copay
Medicare-covered glaucoma screening: $0 copay

網上看診$0 copay[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$6700 for services you receive from in-network providers.

Office Visit for Primary Doctor$10 copay

Office Visit for Specialist$50 copay

Inpatient Hospital CoverageInpatient hospital-acute:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$390 copay per day for days 1 through 5
$0 copay per day for days 6 through 90
$0 copay per day for days 91 and beyond
Inpatient hospital psychiatric:
Our plan covers up to 90 days in an inpatient hospital stay.
$390 copay per day for days 1 through 4
$0 copay per day for days 5 through 90

Prescription Drug Deductible$395
Applies to Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty Tier

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$3.00 copay

Tier 2: Generic$12.00 copay

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug$100.00 copay (after deductible)

Tier 5: Specialty Tier25% coinsurance (after deductible)

Other Coverage Highlights

牙科 Services Oral exams (for up to 2 every year): $0 copay
Prophylaxis (cleaning) (for up to 3 every year): $0 copay
Fluoride treatment (for up to 2 every year): $0 copay
牙科 x-rays (for up to 1 every three years): $0 copay

聽覺 Services 聽覺 exams:
Routine hearing exams (for up to 1 every year): $0 copay
聽覺 aids:
聽覺 aids (all types) (for up to 2 every two years): $375-$2075 copay, depending on the services

眼科 Services Eye exams:
Routine eye exams (for up to 1 every year): $0 copay
Medicare-covered glaucoma screening: $0 copay

健身$0 copay

網上看診$0 copay[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$0 annually for Medicare-covered services from in-network providers.

Office Visit for Primary Doctor$0 copay

Office Visit for Specialist$0 copay

Inpatient Hospital CoverageInpatient hospital-acute:
$0 copay per stay
Our plan covers an unlimited number of days for an inpatient hospital stay.
Inpatient hospital psychiatric:
$0 copay per stay
Our plan covers 90 days for an inpatient hospital stay.

Prescription Drug Deductible$0

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred GenericFor 30-day or 90-day supply from retail network pharmacy:
All Covered Drugs: $0 copay
Some covered drugs limited to a 30-day supply

Tier 2: GenericFor 30-day or 90-day supply from retail network pharmacy:
All Covered Drugs: $0 copay
Some covered drugs limited to a 30-day supply

Tier 3: Preferred BrandFor 30-day or 90-day supply from retail network pharmacy:
All Covered Drugs: $0 copay
Some covered drugs limited to a 30-day supply

Tier 4: Non-Preferred DrugFor 30-day or 90-day supply from retail network pharmacy:
All Covered Drugs: $0 copay
Some covered drugs limited to a 30-day supply

Tier 5: Specialty TierFor 30-day or 90-day supply from retail network pharmacy:
All Covered Drugs: $0 copay
Some covered drugs limited to a 30-day supply

Other Coverage Highlights

牙科 Services Preventive:
$0 copay
Comprehensive:
$0 copay
Benefit limit:
$1,000

聽覺 Services Exam to diagnose and treat hearing and balance issues:
$0 copay
Routine hearing exam:
$0 copay; 1 per year
聽覺 aid:
$2,000 allowance for hearing aids, up to 2 hearing aids every 2 years.

眼科 Services Exam to diagnose and treat diseases and conditions of the eye:
$0 copay
Eyewear after cataract surgery:
$0 copay
Routine eye exam:
$0 copay; 1 every year
Eyewear:
$0 copay every year; up to $200 for lenses/frames and contacts

健身 $0 copay

非處方藥福利$300 credit per quarter to use on approved health products from network retail locations. Order online, over the phone, or by mail through your FirstLine Select Catalog.

網上看診$0 copay; Speak to network telehealth providers using your computer or mobile device.[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket MaximumThis plan does not have a deductible. $6700 for services you receive from in-network providers.

Office Visit for Primary Doctor$0 copay

Office Visit for Specialist$45 copay

Inpatient Hospital CoverageInpatient hospital-acute:
Our plan covers up to 90 days in an inpatient hospital stay.
$650 copay per day for days 1 through 3
$0 copay per day for days 4 through 90
Inpatient hospital psychiatric:
Our plan covers up to 90 days in an inpatient hospital stay.
$575 copay per day for days 1 through 3
$0 copay per day for days 4 through 90

Prescription Drug Deductible$0

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$0.00 copay

Tier 2: Generic$10.00 copay

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug48% coinsurance

Tier 5: Specialty Tier33% coinsurance

Other Coverage Highlights

牙科 Services Oral exams (for up to 1 every six months): $0 copay
Prophylaxis (cleaning) (for up to 1 every six months): $0 copay
Fluoride treatment (for up to 1 every year): $0 copay
牙科 x-rays (for up to 1): $0 copay
Non-routine services (for up to 1): $0 copay
Restorative services (for up to 1 every three years): $0 copay
Periodontics (for up to 1): $0 copay
Extractions (for up to 1): $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services (for up to 1): $0 copay
Our plan pays up to $500 every year for dental services shown above.

聽覺 Services 聽覺 exams:
Routine hearing exams (for up to 1 every year): $0 copay
Fitting/evaluation for hearing aid (for up to 1 every year): $0 copay
聽覺 aids:
聽覺 aids (all types) (for up to 2 every year): $0 copay
Our plan pays up to $1500 every year for hearing aids. The maximum plan benefit coverage amount applies for both ears combined.

眼科 Services Eye exams:
Routine eye exams (for up to 1 every year): $0 copay
Eyewear:
Contact lenses: $0 copay
Eyeglasses (lenses and frames): $0 copay
Eyeglass lenses: $0 copay
Eyeglass frames: $0 copay
Upgrades: $0 copay
Our plan pays up to $100 every year for all eyewear.
Medicare-covered glaucoma screening: $0 copay

健身$0 copay

非處方藥福利$0 copay. Up to $55 every three months copay

免費接送$0 copay, 12 trips every year by Taxi or Rideshare Services or Van (one-way) to plan approved health-related location.

網上看診$0-$45 copay, depending on the service[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$6700 for services you receive from in-network providers.

Office Visit for Primary Doctor$0 copay

Office Visit for Specialist$25 copay

Inpatient Hospital CoverageInpatient hospital-acute:
Our plan covers up to 90 days in an inpatient hospital stay.
$500 copay per day for days 1 through 3
$0 copay per day for days 4 through 90
Inpatient hospital psychiatric:
Our plan covers up to 90 days in an inpatient hospital stay.
$475 copay per day for days 1 through 3
$0 copay per day for days 4 through 90

Prescription Drug Deductible$0

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$0.00 copay

Tier 2: Generic$15.00 copay

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug48% coinsurance

Tier 5: Specialty Tier33% coinsurance

Other Coverage Highlights

牙科 Services Oral exams (for up to 1 every six months): $0 copay
Prophylaxis (cleaning) (for up to 1 every six months): $0 copay
Fluoride treatment (for up to 1 every year): $0 copay
牙科 x-rays (for up to 1): $0 copay
Non-routine services (for up to 1): $0 copay
Restorative services (for up to 1 every three years): $0 copay
Periodontics (for up to 1): $0 copay
Extractions (for up to 1): $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services (for up to 1): $0 copay
Our plan pays up to $750 every year for dental services shown above.

眼科 Services Medicare-covered glaucoma screening:$0 copay

健身$0 copay

非處方藥福利$0 copay. Up to $35 every three months

免費接送$0 copay, 12 trips every year by Taxi or Rideshare Services or Van (one-way) to plan approved health-related location.

網上看診$0-$40 copay, depending on the service[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$6700 for services you receive from in-network providers. $6700 for services you receive from any provider.

Office Visit for Primary DoctorIn-network: $5 copay
Out-of-network: $25 copay

Office Visit for SpecialistIn-network: $35 copay
Out-of-network: $60 copay

Inpatient Hospital CoverageInpatient hospital-acute:
In-network:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$325 copay per day for days 1 through 6
$0 copay per day for days 7 through 90
You pay nothing per day for days 91 and beyond
Out-of-network:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$388 copay per day for days 1 through 7
$0 copay per day for days 8 and beyond
Inpatient hospital psychiatric:
In-network:
Our plan covers up to 90 days in an inpatient hospital stay.
$295 copay per day for days 1 through 5
$0 copay per day for days 6 through 90
Out-of-network:
Our plan covers up to 90 days in an inpatient hospital stay.
$300 copay per day for days 1 through 7
$0 copay per day for days 8 through 90

Prescription Drug Deductible$0

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$5.00 copay

Tier 2: Generic$12.00 copay

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug$100.00 copay coinsurance

Tier 5: Specialty Tier33% coinsurance

Other Coverage Highlights

牙科 Services Oral exams (for up to 1 every six months):
In-network: $0 copay
Out-of-network: 50% coinsurance
Prophylaxis (cleaning) (for up to 1 every six months):
In-network: $0 copay
Out-of-network: 50% coinsurance
Fluoride treatment (for up to 1 every year):
In-network: $0 copay
Out-of-network: 50% coinsurance
牙科 x-rays (for up to 1):
In-network: $0 copay
Out-of-network: 50% coinsurance
Non-routine services (for up to 1):
In-network: $0 copay
Out-of-network: 50% coinsurance or $60 copay, depending on the service
Restorative services (for up to 1 every three years):
In-network: $0 copay
Out-of-network: 50% coinsurance or $60 copay, depending on the service
Periodontics (for up to 1):
In-network: $0 copay
Out-of-network: 50% coinsurance or $60 copay, depending on the service
Extractions (for up to 1):
In-network: $0 copay
Out-of-network: 50% coinsurance or $60 copay, depending on the service
Prosthodontics, other oral/maxillofacial surgery, other services (for up to 1):
In-network: $0 copay
Out-of-network: 50% coinsurance or $60 copay, depending on the service
Our plan pays up to $500 every year for dental services shown above. The maximum plan benefit coverage amount applies to both in-network and out-of-network services.

聽覺 Services 聽覺 exams:Routine hearing exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: 40% coinsurance or $60 copay, depending on the service
Fitting/evaluation for hearing aid (for up to 1 every year):
In-network: $0 copay
Out-of-network: 40% coinsurance or $60 copay, depending on the service
聽覺 aids:
聽覺 aids (all types) (for up to 2 every year):
In-network: $0 copay
Out-of-network: 40% coinsurance
Our plan pays up to $1500 every year for hearing aids. The maximum plan benefit coverage amount applies to both in-network and out-of-network services. The maximum plan benefit coverage amount applies for both ears combined.

眼科 Services Eye exams:Routine eye exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: 40% coinsurance or $0-$60 copay, depending on the service
Eyewear:
Contact lenses:
In-network: $0 copay
Out-of-network: 40% coinsurance or $60 copay, depending on the service
Eyeglasses (lenses and frames):
In-network: $0 copay
Out-of-network: 40% coinsurance or $60 copay, depending on the service
Eyeglass lenses:
In-network: $0 copay
Out-of-network: 40% coinsurance or $60 copay, depending on the service
Eyeglass frames:
In-network: $0 copay
Out-of-network: 40% coinsurance or $60 copay, depending on the service
Upgrades:
In-network: $0 copay
Out-of-network: 40% coinsurance or $60 copay, depending on the service
Our plan pays up to $100 every year for all eyewear.The maximum plan benefit coverage amount applies to both in-network and out-of-network services.
Medicare-covered glaucoma screening:
In-network: $0 copay
Out-of-network: $0 copay

健身In-network: $0 copay
Out-of-network: $0 copay

非處方藥福利In-network: $0 copay. Up to $90 every three months
Out-of-network: The in-network provider must be used for the out-of-network benefit.

網上看診$0-$40 copay, depending on the service[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$7550 for services you receive from in-network providers. $11300 for services you receive from any provider.

Office Visit for Primary DoctorIn-network: $0 copay
Out-of-network: $25 copay

Office Visit for SpecialistIn-network: $45 copay
Out-of-network: 40% coinsurance

Inpatient Hospital CoverageInpatient hospital-acute:
In-network:
Our plan covers up to 90 days in an inpatient hospital stay.
$275 copay per day for days 1 through 6
$0 copay per day for days 7 through 90
Out-of-network:
Our plan covers up to 90 days in an inpatient hospital stay.
20% coinsurance per day for days 1 through 90
Inpatient hospital psychiatric:
In-network:
Our plan covers up to 90 days in an inpatient hospital stay.
$300 copay per day for days 1 through 6
$0 copay per day for days 7 through 90
Out-of-network:
Our plan covers up to 90 days in an inpatient hospital stay.
40% coinsurance per day for days 1 through 90

Prescription Drug Deductible$150
Applies to Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty Tier

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$0.00 copay

Tier 2: Generic$12.00 copay

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug$100.00 copay coinsurance

Tier 5: Specialty Tier30% coinsurance

Other Coverage Highlights

牙科 Services Oral exams (for up to 1 every six months):
In-network: $0 copay
Out-of-network: 50% coinsurance
Prophylaxis (cleaning) (for up to 1 every six months):
In-network: $0 copay
Out-of-network: 50% coinsurance
Fluoride treatment (for up to 1 every year):
In-network: $0 copay
Out-of-network: 50% coinsurance
牙科 x-rays (for up to 1):
In-network: $0 copay
Out-of-network: 50% coinsurance
Non-routine services (for up to 1):
In-network: $0 copay
Out-of-network: 40%-50% coinsurance, depending on the service
Periodontics (for up to 1):
In-network: $0 copay
Out-of-network: 40%-50% coinsurance, depending on the service

聽覺 Services 聽覺 exams:Routine hearing exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: 40% coinsurance
Fitting/evaluation for hearing aid (for up to 1 every year):
In-network: $0 copay
Out-of-network: 40% coinsurance
聽覺 aids:
聽覺 aids (all types) (for up to 2 every year):
In-network: $0 copay
Out-of-network: 40% coinsurance
Our plan pays up to $700 every year for hearing aids. The maximum plan benefit coverage amount applies to both in-network and out-of-network services. The maximum plan benefit coverage amount applies for both ears combined.

眼科 Services Eye exams:Routine eye exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: $0 copay or 40% coinsurance, depending on the service
Eyewear:
Contact lenses:
In-network: $0 copay
Out-of-network: 40% coinsurance
Eyeglasses (lenses and frames):
In-network: $0 copay
Out-of-network: 40% coinsurance
Eyeglass lenses:
In-network: $0 copay
Out-of-network: 40% coinsurance
Eyeglass frames:
In-network: $0 copay
Out-of-network: 40% coinsurance
Upgrades:
In-network: $0 copay
Out-of-network: 40% coinsurance
Our plan pays up to $100 every year for all eyewear.The maximum plan benefit coverage amount applies to both in-network and out-of-network services.
Medicare-covered glaucoma screening:
In-network: $0 copay
Out-of-network: $0 copay

健身In-network: $0 copay
Out-of-network: $0 copay

非處方藥福利In-network: $0 copay. Up to $25 every three months
Out-of-network: The in-network provider must be used for the out-of-network benefit.

網上看診$0-$40 copay, depending on the service[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$6700 for services you receive from in-network providers. $10000 for services you receive from any provider.

Office Visit for Primary DoctorIn-network: $0 copay
Out-of-network: $0 copay

Office Visit for SpecialistIn-network: $35 copay
Out-of-network: $35 copay

Inpatient Hospital CoverageInpatient hospital-acute:
In-network:
Our plan covers up to 90 days in an inpatient hospital stay.
$450 copay per day for days 1 through 4
$0 copay per day for days 5 through 90
Out-of-network:
Our plan covers up to 90 days in an inpatient hospital stay.
$450 copay per day for days 1 through 4
$0 copay per day for days 5 through 90
Inpatient hospital psychiatric:
In-network:
Our plan covers up to 90 days in an inpatient hospital stay.
$465 copay per day for days 1 through 4
$0 copay per day for days 5 through 90
Out-of-network:
Our plan covers up to 90 days in an inpatient hospital stay.
$465 copay per day for days 1 through 4
$0 copay per day for days 5 through 90

Prescription Drug Deductible$445
Applies to Tier 2: Generic, Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty Tier

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$0.00 copay

Tier 2: Generic$20.00 copay (after deductible)

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug50% coinsurance (after deductible)

Tier 5: Specialty Tier25% coinsurance (after deductible)

Other Coverage Highlights

牙科 Services Oral exams (for up to 1 every six months):
In-network: $0 copay
Out-of-network: 50% coinsurance
Prophylaxis (cleaning) (for up to 1 every six months):
In-network: $0 copay
Out-of-network: 50% coinsurance
Fluoride treatment (for up to 1 every year):
In-network: $0 copay
Out-of-network: 50% coinsurance
牙科 x-rays (for up to 1):
In-network: $0 copay
Out-of-network: 50% coinsurance
Non-routine services (for up to 1):
In-network: $0 copay
Out-of-network: $35 copay or 50% coinsurance, depending on the service
Diagnostic services (for up to 1 every year):
In-network: $0 copay
Out-of-network: $35 copay or 50% coinsurance, depending on the service
Restorative services (for up to 1 every three years):
In-network: $0 copay
Out-of-network: $35 copay or 50% coinsurance, depending on the service
Endodontics (for up to 1):
In-network: $0 copay
Out-of-network: $35 copay or 50% coinsurance, depending on the service
Periodontics (for up to 1):
In-network: $0 copay
Out-of-network: $35 copay or 50% coinsurance, depending on the service
Extractions (for up to 1):
In-network: $0 copay
Out-of-network: $35 copay or 50% coinsurance, depending on the service
Prosthodontics, other oral/maxillofacial surgery, other services (for up to 1):
In-network: $0 copay
Out-of-network: $35 copay or 50% coinsurance, depending on the service
Our plan pays up to $1000 every year for dental services shown above. The maximum plan benefit coverage amount applies to both in-network and out-of-network services.

聽覺 Services 聽覺 exams:Routine hearing exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: $35 copay or 40% coinsurance, depending on the service
Fitting/evaluation for hearing aid (for up to 1 every year):
In-network: $0 copay
Out-of-network: $35 copay or 40% coinsurance, depending on the service
聽覺 aids:
聽覺 aids (all types) (for up to 2 every year):
In-network: $0 copay
Out-of-network: 40% coinsurance
Our plan pays up to $1500 every year for hearing aids. The maximum plan benefit coverage amount applies to both in-network and out-of-network services. The maximum plan benefit coverage amount applies for both ears combined.

眼科 Services Eye exams:Routine eye exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: 40% coinsurance or $0-$35 copay, depending on the service
Eyewear:
Contact lenses:
In-network: $0 copay
Out-of-network: 40% coinsurance or $35 copay, depending on the service
Eyeglasses (lenses and frames):
In-network: $0 copay
Out-of-network: 40% coinsurance or $35 copay, depending on the service
Eyeglass lenses:
In-network: $0 copay
Out-of-network: 40% coinsurance or $35 copay, depending on the service
Eyeglass frames:
In-network: $0 copay
Out-of-network: 40% coinsurance or $35 copay, depending on the service
Upgrades:
In-network: $0 copay
Out-of-network: 40% coinsurance or $35 copay, depending on the service
Our plan pays up to $100 every year for all eyewear.The maximum plan benefit coverage amount applies to both in-network and out-of-network services.
Medicare-covered glaucoma screening:
In-network: $0 copay
Out-of-network: $0 copay

健身n-network: $0 copay
Out-of-network: $0 copay

非處方藥福利In-network: $0 copay. Up to $120 every three months
Out-of-network: The in-network provider must be used for the out-of-network benefit.

網上看診$0-$40 copay, depending on the service[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$6700 for services you receive from in-network providers.

Office Visit for Primary Doctor$0 copay

Office Visit for Specialist$40 copay

Inpatient Hospital CoverageInpatient hospital-acute:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$600 copay per day for days 1 through 3
$0 copay per day for days 4 through 90
You pay nothing per day for days 91 and beyond
Inpatient hospital psychiatric:
Our plan covers up to 90 days in an inpatient hospital stay.
$575 copay per day for days 1 through 3
$0 copay per day for days 4 through 90

Prescription Drug Deductible$445
Applies to Tier 2: Generic, Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty Tier

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$0.00 copay

Tier 2: Generic$20.00 copay (after deductible)

Tier 3: Preferred Brand$47.00 copay (after deductible)

Tier 4: Non-Preferred Drug50% coinsurance (after deductible)

Tier 5: Specialty Tier25% coinsurance (after deductible)

Other Coverage Highlights

牙科 Services Oral exams (for up to 1 every six months): $0 copay
Prophylaxis (cleaning) (for up to 1 every six months): $0 copay
Fluoride treatment (for up to 1 every year): $0 copay
牙科 x-rays (for up to 1): $0 copay
Non-routine services (for up to 1): $0 copay
Restorative services (for up to 1 every three years): $0 copay
Periodontics (for up to 1): $0 copay
Extractions (for up to 1): $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services (for up to 1): $0 copay
Our plan pays up to $500 every year for dental services shown above.

聽覺 Services 聽覺 exams:Routine hearing exams (for up to 1 every year):
Routine hearing exams (for up to 1 every year): $0 copay
Fitting/evaluation for hearing aid (for up to 1 every year): $0 copay
聽覺 aids:
聽覺 aids (all types) (for up to 2 every year): $0 copay
Our plan pays up to $1500 every year for hearing aids. The maximum plan benefit coverage amount applies for both ears combined.

眼科 Services Eye exams:
Routine eye exams (for up to 1 every year): $0 copay
Eyewear:
Contact lenses: $0 copay
Eyeglasses (lenses and frames): $0 copay
Eyeglass lenses: $0 copay
Eyeglass frames: $0 copay
Upgrades: $0 copay
Our plan pays up to $100 every year for all eyewear.
Medicare-covered glaucoma screening: $0 copay

健身$0 copay

非處方藥福利$0 copay. Up to $95 every three months

免費接送$0 copay, 36 trips every year by Taxi or Rideshare Services or Van (one-way) to plan approved health-related location.

網上看診$0-$40 copay, depending on the service[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$6700 for services you receive from in-network providers.

Office Visit for Primary Doctor$0 copay

Office Visit for Specialist$30 copay

Inpatient Hospital CoverageInpatient hospital-acute:
Our plan covers up to 90 days in an inpatient hospital stay.
$295 copay per day for days 1 through 6
$0 copay per day for days 7 through 90
Inpatient hospital psychiatric:
Our plan covers up to 90 days in an inpatient hospital stay.
$200 copay per day for days 1 through 6
$0 copay per day for days 7 through 90

Prescription Drug Deductible$0

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$0.00 copay

Tier 2: Generic$15.00 copay

Tier 3: Preferred Brand$47.00 copay

Tier 4: Non-Preferred Drug48% coinsurance

Tier 5: Specialty Tier33% coinsurance

Other Coverage Highlights

牙科 Services Oral exams (for up to 1 every six months): $0 copay
Prophylaxis (cleaning) (for up to 1 every six months): $0 copay
Fluoride treatment (for up to 1 every year): $0 copay
牙科 x-rays (for up to 1): $0 copay
Non-routine services (for up to 1): $0 copay
Diagnostic services (for up to 1 every year): $0 copay
Restorative services (for up to 1 every three years): $0 copay
Endodontics (for up to 1): $0 copay
Periodontics (for up to 1): $0 copay
Extractions (for up to 1): $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services (for up to 1): $0 copay
Our plan pays up to $1000 every year for dental services shown above.

聽覺 Services 聽覺 exams:
Routine hearing exams (for up to 1 every year): $0 copay
Fitting/evaluation for hearing aid (for up to 1 every year): $0 copay
聽覺 aids:
聽覺 aids (all types) (for up to 2 every year): $0 copay
Our plan pays up to $1500 every year for hearing aids. The maximum plan benefit coverage amount applies for both ears combined.

眼科 Services Eye exams:
Routine eye exams (for up to 1 every year): $0 copay
Eyewear:
Contact lenses: $0 copay
Eyeglasses (lenses and frames): $0 copay
Eyeglass lenses: $0 copay
Eyeglass frames: $0 copay
Upgrades: $0 copay
Our plan pays up to $200 every year for all eyewear.
Medicare-covered glaucoma screening: $0 copay

健身$0 copay

非處方藥福利$0 copay. Up to $30 every three months

免費接送$0 copay, 12 trips every year by Taxi or Rideshare Services or Van (one-way) to plan approved health-related location.

網上看診$0-$40 copay, depending on the service[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network DeductibleThis plan does not have a deductible.

Out-of-Pocket Maximum$3400 for services you receive from in-network providers. $3400 for services you receive from any provider.

Office Visit for Primary DoctorIn-network: $0 copay
Out-of-network: $10 copay

Office Visit for SpecialistIn-network: $25 copay
Out-of-network: $35 copay

Inpatient Hospital CoverageInpatient hospital-acute:
In-network:
Our plan covers an unlimited number of days for an inpatient hospital stay.
Copayment amount for the medicare-covered stay: $600 copay
Out-of-network:
Our plan covers an unlimited number of days for an inpatient hospital stay.
$350 copay per day for days 1 through 7
$0 copay per day for days 8 and beyond
Inpatient hospital psychiatric:
In-network:
Copayment amount for the medicare-covered stay: $500 copay
Out-of-network:
Our plan covers up to 90 days in an inpatient hospital stay.
$300 copay per day for days 1 through 7
$0 copay per day for days 8 through 90

Prescription Drug Deductible$0

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred Generic$5.00 copay/span>

Tier 2: Generic$10.00 copay

Tier 3: Preferred Brand$45.00 copay

Tier 4: Non-Preferred Drug$85.00 copay

Tier 5: Specialty Tier33% coinsurance

Other Coverage Highlights

牙科 Services Oral exams (for up to 1 every six months):
In-network: $0 copay
Out-of-network: 50% coinsurance
Prophylaxis (cleaning) (for up to 1 every six months):
In-network: $0 copay
Out-of-network: 50% coinsurance
Fluoride treatment (for up to 1 every year):
In-network: $0 copay
Out-of-network: 50% coinsurance
牙科 x-rays (for up to 1):
In-network: $0 copay
Out-of-network: 50% coinsurance
Non-routine services (for up to 1):
In-network: $0 copay
Out-of-network: $35 copay or 50% coinsurance, depending on the service
Restorative services (for up to 1 every three years):
In-network: $0 copay
Out-of-network: $35 copay or 50% coinsurance, depending on the service
Periodontics (for up to 1):
In-network: $0 copay
Out-of-network: $35 copay or 50% coinsurance, depending on the service
Extractions (for up to 1):
In-network: $0 copay
Out-of-network: $35 copay or 50% coinsurance, depending on the service
Prosthodontics, other oral/maxillofacial surgery, other services (for up to 1):
In-network: $0 copay
Out-of-network: $35 copay or 50% coinsurance, depending on the service
Our plan pays up to $500 every year for dental services shown above. The maximum plan benefit coverage amount applies to both in-network and out-of-network services.

聽覺 Services 聽覺 exams:
Routine hearing exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: 40% coinsurance or $35 copay, depending on the service
Fitting/evaluation for hearing aid (for up to 1 every year):
In-network: $0 copay
Out-of-network: 40% coinsurance or $35 copay, depending on the service
聽覺 aids:
聽覺 aids (all types) (for up to 2 every year):
In-network: $0 copay
Out-of-network: 40% coinsurance
Our plan pays up to $1500 every year for hearing aids. The maximum plan benefit coverage amount applies to both in-network and out-of-network services. The maximum plan benefit coverage amount applies for both ears combined.

眼科 Services Eye exams:
Routine eye exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: 40% coinsurance or $0-$35 copay, depending on the service
Eyewear:
Contact lenses:
In-network: $0 copay
Out-of-network: 40% coinsurance or $35 copay, depending on the service
Eyeglasses (lenses and frames):
In-network: $0 copay
Out-of-network: 40% coinsurance or $35 copay, depending on the service
Eyeglass lenses:
In-network: $0 copay
Out-of-network: 40% coinsurance or $35 copay, depending on the service
Eyeglass frames:
In-network: $0 copay
Out-of-network: 40% coinsurance or $35 copay, depending on the service
Upgrades:
In-network: $0 copay
Out-of-network: 40% coinsurance or $35 copay, depending on the service
Our plan pays up to $100 every year for all eyewear.The maximum plan benefit coverage amount applies to both in-network and out-of-network services.
Medicare-covered glaucoma screening:
In-network: $0 copay
Out-of-network: $0 copay

健身In-network: $0 copay
Out-of-network: $0 copay

非處方藥福利In-network: $0 copay. Up to $90 every three months
Out-of-network: The in-network provider must be used for the out-of-network benefit.

網上看診$0-$40 copay, depending on the service[/accordion_son][/accordion_father]

[accordion_father][accordion_son title=”View More Details”]

Coverage Highlights

Star Rating

Annual In-Network Deductible0$

Out-of-Pocket Maximum$3450 for services you receive from in-network providers. $5150 for services you receive from any provider.

Office Visit for Primary DoctorIn-network: $0 co-pay
Out-of-network: $0 co-pay

Office Visit for SpecialistIn-network: $0 co-pay
Out-of-network: $0 co-pay

Inpatient Hospital CoverageInpatient hospital-acute:
In-network:
$0 co-pay up to 90 days per admission
Out-of-network:
$0 co-pay up to 90 days per admission
Inpatient hospital psychiatric:
In-network:
$0 co-pay up to 90 days per admission
Out-of-network:
$0 co-pay up to 90 days per admission

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred GenericOne-month supply:
You pay $0

Tier 2: GenericOne-month supply:
Generics: You pay $0 or $1.30 or $3.70 or 15%
Brands: You pay $0 or $4.00 or $9.20 or 15%

Tier 3: Preferred BrandOne-month supply:
Generics: You pay $0 or $1.30 or $3.70 or 15%
Brands: You pay $0 or $4.00 or $9.20 or 15%

Tier 4: Non-Preferred DrugOne-month supply:
Generics: You pay $0 or $1.30 or $3.70 or 15%
Brands: You pay $0 or $4.00 or $9.20 or 15%

Tier 5: Specialty TierOne-month supply:
Generics: You pay $0 or $1.30 or $3.70 or 15%
Brands: You pay $0 or $4.00 or $9.20 or 15%

Other Coverage Highlights

牙科 Services Oral exams (for up to 1 every six months):
In-network: $0 copay
Out-of-network: 50% coinsurance
Prophylaxis (cleaning) (for up to 1 every six months):
In-network: $0 copay
Out-of-network: 50% coinsurance
Fluoride treatment (for up to 1 every year):
In-network: $0 copay
Out-of-network: 50% coinsurance
牙科 x-rays (for up to 1):
In-network: $0 copay
Out-of-network: 50% coinsurance
Routine services:
In-network: $0 copay
Out-of-network: 50% coinsurance
Non-routine services (for up to 1):
$0 copay
Restorative services (for up to 1 every three years):
$0 copay
Endodontics (for up to 1):
$0 copay
Periodontics (for up to 1):
$0 copay
Extractions (for up to 1):
$0 copay
Prosthodontics, other oral/maxillofacial surgery, other services (for up to 1):
$0 copay
Our plan pays up to $1000 every year for dental services shown above. The maximum plan benefit coverage amount applies to both in-network and out-of-network services.

聽覺 Services 聽覺 exams:
Routine hearing exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: 40% coinsurance
Fitting/evaluation for hearing aid (for up to 1 every year):
In-network: $0 copay
Out-of-network: 40% coinsurance, depending on the service
聽覺 aids:
聽覺 aids (all types) (for up to 2 every year):
In-network: $0 copay
Out-of-network: 40% coinsurance
Our plan pays up to $2000 every year for hearing aids. The maximum plan benefit coverage amount applies to both in-network and out-of-network services. The maximum plan benefit coverage amount applies for both ears combined.

眼科 Services Eye exams:
Routine eye exams (for up to 1 every year):
In-network: $0 copay
Out-of-network: 40% coinsurance
Eyewear:
Contact lenses:
In-network: $0 copay
Out-of-network: 40% coinsurance
Eyeglasses (lenses and frames):
In-network: $0 copay
Out-of-network: 40% coinsurance
Eyeglass lenses:
In-network: $0 copay
Out-of-network: 40% coinsurance
Eyeglass frames:
In-network: $0 copay
Out-of-network: 40% coinsurance
Our plan pays up to $200 every year for all eyewear.The maximum plan benefit coverage amount applies to both in-network and out-of-network services.
Medicare-covered glaucoma screening:
In-network: $0 copay
Out-of-network: $0 copay

健身$0 copay

非處方藥福利The maximum total annual benefit is $960.

免費接送In-network: $0 copay, 12 trips every year by Taxi or Rideshare Services or Van (one-way) to plan approved health-related location.
Out-of-network: 75% coinsurance

網上看診In-network:$0 copay
Out-of-network:$0 copay[/accordion_son][/accordion_father]

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Coverage Highlights

Star Rating

Annual In-Network Deductible0$

Out-of-Pocket Maximum$3450 for services you receive from in-network providers.

Office Visit for Primary Doctor$0 co-pay

Office Visit for Specialist$0 co-pay

Inpatient Hospital CoverageInpatient hospital-acute:
$0 co-pay up to 90 days per admission
Inpatient hospital psychiatric:
$0 co-pay up to 90 days per admission

Prescription Drug Deductible$0
Applies to Tier 2: Generic, Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty Tier

Prescription Drug Coverage (Initial Coverage, Standard Retail Cost-Sharing, 30-Day)

Tier 1: Preferred GenericOne-month supply:
You pay $0

Tier 2: GenericOne-month supply:
Generics: You pay $0 or $1.30 or $3.70 or 15%
Brands: You pay $0 or $4.00 or $9.20 or 15%

Tier 3: Preferred BrandOne-month supply:
Generics: You pay $0 or $1.30 or $3.70 or 15%
Brands: You pay $0 or $4.00 or $9.20 or 15%

Tier 4: Non-Preferred DrugOne-month supply:
Generics: You pay $0 or $1.30 or $3.70 or 15%
Brands: You pay $0 or $4.00 or $9.20 or 15%

Tier 5: Specialty TierOne-month supply:
Generics: You pay $0 or $1.30 or $3.70 or 15%
Brands: You pay $0 or $4.00 or $9.20 or 15%

Other Coverage Highlights

牙科 Services Oral exams (for up to 1 every six months): $0 copay
Prophylaxis (cleaning) (for up to 1 every six months): $0 copay
Fluoride treatment (for up to 1 every year): $0 copay
牙科 x-rays (for up to 1): $0 copay
Non-routine services (for up to 1): $0 copay
Diagnostic services (for up to 1 every year): $0 copay
Restorative services (for up to 1 every three years): $0 copay
Endodontics (for up to 1): $0 copay
Periodontics (for up to 1): $0 copay
Extractions (for up to 1): $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services (for up to 1): $0 copay
Our plan pays up to $1000 every year for dental services shown above.

聽覺 Services 聽覺 exams:
Routine hearing exams (for up to 1 every year): $0 copay
Fitting/evaluation for hearing aid (for up to 1 every year): $0 copay
聽覺 aids:
聽覺 aids (all types) (for up to 2 every year): $0 copay
Our plan pays up to $1500 every year for hearing aids. The maximum plan benefit coverage amount applies for both ears combined.

眼科 Services Eye exams:
Routine eye exams (for up to 1 every year): $0 copay
Eyewear:
Contact lenses: $0 copay
Eyeglasses (lenses and frames): $0 copay
Eyeglass lenses: $0 copay
Eyeglass frames: $0 copay
Our plan pays up to $100 every year for all eyewear.
Medicare-covered glaucoma screening: $0 copay

健身$0 copay

非處方藥福利The maximum total annual benefit is $1,800.

免費接送$0 copay, 24 trips every year by Taxi or Rideshare Services or Van (one-way) to plan approved health-related location.

網上看診$0 copay[/accordion_son][/accordion_father]