2023 Preferred (HMO) Plan

$0

Gap Coverage: In 2023, once you and your plan have spent $4,660 on covered drugs combined, you're in the Coverage Gap Stage where the 30 day supply costs: $0 for Tier 6 drugs and 25% of the cost for Part D generic and brand name drugs, plus a portion of the dispensing fee for Tiers 1-5.

Catastrophic Coverage: In 2023, once you've spent $7,400 in out-of-pocket prescription costs you are in the Catastrophic Coverage Stage where the 30 day supply costs: The greater of $4.15 for generic prescriptions, $10.35 for brand name prescriptions, or 5% of the prescription price.

Initial Coverage Stage

$0 for 30 day retail supply; $0 for 90 day mail order supply

Initial Coverage Stage

$0 for 30 day retail supply; $0 for 90 day mail order supply

Initial Coverage Stage

$47 for 30 day retail supply; $94 for 90 day mail order supply

Initial Coverage Stage

$100 for 30 day retail supply; $200 for 90 day mail order supply

Initial Coverage Stage

33% of cost for 30 day retail supply

$0

$0

$4,900

$0 per visit

$0 copay for e-visits and virtual check-ins;
For all other telehealth visits, copay is the same as corresponding in-person visit copay

$0 per day for Lab Services

$15 per annual visit

$0 per annual visit

$45 per visit

$30 per day

$30 per day

Ultrasound: $60 per day; Others: $250 per day

Colonoscopies: $0; Others (ASC): $270 per day; Others (Non-ASC): $370 per day

$30 per visit

$0 per annual visit

$0 per annual visit

$0

PCP: $0; Specialist: $45 per visit; Urgent Care Center: $45 per visit.

$90 per visit

$475 per day for days 1-4; $0 per day for day 5 and beyond

$300 per day

$100 on Class 2 and 3 Services

The plan pays up to the calendar year maximum of $1,500.

$0 copay; Two per year.

$0 copay; Once every 36 months (includes the initial dental history and charting of teeth). 

$0 copay; Two per year (when oral conditions indicate need).

50% coinsurance after deductible; Once every 60 months.

50% coinsurance after deductible; As needed.

50% coinsurance after deductible; Once every 6 months following active periodontal therapy, not to be combined with regular cleanings

50% coinsurance after deductible; Once per tooth. 

50% after deductible; Once per tooth.

50% coinsurance after deductible; Once every 24 months per bridge or denture.

50% coinsurance after deductible; Once per arch within 84 months.

50% coinsurance after deductible; Once within 84 months per tooth (when teeth cannot be restored with regular filings due to fracture or decay).

$1,500 yearly maximum. $0 for preventive services such as cleanings and oral exams, 50% coinsurance for restorative services such as fillings and simple extractions, and 50% coinsurance for major services such as dentures, bridges, and crowns. $100 deductible on restorative and major services. No waiting period.

$325 CarePerks health and wellness allowance. ($150 reimbursement towards weight management programs like WeightWatchers, Jenny Craig, and hospital-based programs. $175 wellness benefit good towards a fitness tracker once every 3 years, a membership at a qualified health club or fitness facility, yoga classes, memory fitness and nutritional programs).

You receive a SilverSneakers fitness membership at no additional cost giving you access to 16,000+ gyms nationwide, trained instructors, classes and health and nutrition tips with exercise videos.

$50 every calendar quarter for the purchase of covered over-the-counter (OTC) items such as bandages and toothbrushes. (Catalog + Retail)

$20 per visit

You are covered for up to 2 hearing aids per year, 1 aid per ear. Different copays apply.

$250 Standard Level

$475 Superior Level

$650 Advanced Level

$850 Advanced Plus Level

$1,150 Premier Level

$150 annual allowance through EyeMed; $90 per calendar year for non-Eyemed provider.