In-network benefits

When you go to a doctor or hospital that accepts this plan, that's called getting your care in-network.

Because this plan is a PPO, it'll share the cost for some services if you go to a doctor or hospital that doesn't take this plan. That's called getting your care out-of-network. Those benefits are listed on a separate table below.

Your in-network deductible

This plan has no deductible. That means your plan starts sharing the costs of your covered benefits right away.

What we call it What it is When you pay What you pay
Preventive care Exams, prescriptions, tests and shots you get when you're well to prevent illness and injury Anytime
$0
Pediatric services
Children can get pediatric benefits until the end of the calendar year in which they turn 19.
Checkups children get when they're well
Anytime $0
Ambulatory services Office visit to your primary care doctor Anytime 10%
Office visit to a specialist Anytime 10%
Laboratory and diagnostic services

Includes:

  • Lab tests
  • Radiology services like X-rays, EKGs and ultrasounds
  • Allergy testing and shots
  • Imaging services like MRIs
Anytime 10%
What we call it
What it is
When you pay
What you pay
Maternity and newborn care

Doctor office visits while pregnant

  • Tests and ultrasounds you get during the visit are billed under laboratory services
Anytime $0
Care you get when you deliver your baby in the hospital Anytime
10%
Emergency services
Emergency room visit
Anytime 10%
Transportation by ambulance Anytime 10%
Urgent care center visit Anytime 10%
Hospitalization and other services
Care you get when you’re in the hospital for at least one night Anytime 10%
Hospice care Anytime $0
Most other services, like inpatient and outpatient surgery, chemotherapy, home health care and sleep studies Anytime 10%
What we call it What it is When you pay What you pay

Rehabilitative and habilitative services and devices


Services that help you recover from or manage an injury or illness, like:
  • Physical and occupational therapy
  • Spinal manipulation from a chiropractor
  • Speech therapy
  • Diabetes supplies
Anytime 10%
Durable medical equipment, like a wheelchair, walker or oxygen tank Anytime 50%
Mental health/substance abuse Care you get at a mental health or substance abuse facility as an inpatient Anytime 10%
Office visit to an outpatient mental health or substance abuse facility Anytime 10%

Out-of-network benefits

What you'll pay if you go to a doctor or hospital that doesn't accept this plan.

Your out-of-network deductible

This plan has no deductible. That means your plan starts sharing the costs of your covered benefits right away.

What we call it What it is When you pay What you pay
Preventive care Exams, prescriptions, tests and shots you get when you're well to prevent illness and injury. Anytime
All costs
Pediatric services
Children can get pediatric benefits until the end of the calendar year in which they turn 19.
Checkups children get when they're well. Anytime
All costs
Ambulatory services Office visit to your primary care doctor Anytime
All costs
Office visit to a specialist
Anytime All costs
Laboratory and diagnostic services

Includes:

  • Lab tests
  • Radiology services like X-rays, EKGs and ultrasounds
  • Imaging services like MRIs
Anytime 30%
Allergy testing and shots Anytime All costs
What we call it
What it is
When you pay
What you pay
Maternity and newborn care

Doctor office visit while pregnant

  • Tests and ultrasounds you get during the visit are billed under laboratory services
Anytime 30%
Care you get when you deliver your baby in the hospital Anytime 30%
Emergency services
Emergency room visit
Anytime 10%
Transportation by ambulance Anytime 10%
Urgent care center visit
Anytime 30%
Hospitalization and other services
Care you get when you’re in the hospital for at least one night Anytime 30%
Hospice care
Anytime All costs
Most other services, like inpatient and outpatient surgery, chemotherapy and sleep studies Anytime 30%
What we call it What it is When you pay What you pay

Rehabilitative and habilitative services and devices


Services that help you recover from or manage an injury or illness, like:
  • Physical and occupational therapy
  • Spinal manipulation from a chiropractor
  • Speech therapy
  • Diabetes supplies
Anytime 30%
Durable medical equipment, like a wheelchair, walker or oxygen tank Anytime 70%
Mental health/substance abuse Mental health care you get as an inpatient in a hospital or residential facility Anytime 30%
Mental health care you get as an outpatient Anytime 30%
Treatment you get for substance abuse as an inpatient in a hospital or residential facility Anytime All costs
Treatment you get for substance abuse as an outpatient Anytime All costs