$46.20 premium
$2,150 on a Flex Card to pay for out-of-pocket costs, including:
$1,100 to pay for prescription hearing aids
$450 to pay for eyewear like eyeglasses and contact lenses from your choice of hundreds of participating providers and retailers
$600 ($150 available per quarter) for over-the-counter health-related products that you can purchase at major retailers or online
$0 deductible for in-network medical services
$0 copay for in-network primary care provider visits
$0 copay for up to a three-month supply of Tier 1 generics at preferred retail pharmacies and by preferred mail order
See a specialist without a referral
Dental, vision, hearing, fitness center membership
HMO-POS plan includes a network of providers with a point-of-service option that allows care outside of the network (certain restrictions apply)
In-Network Medical |
|||
|---|---|---|---|
| HMO-POS | |||
| Premium | $46.20 Per Month | ||
| Medical Deductible | $0 Per Year | ||
| Preventive Care | $0 Copay | ||
| Primary Care Visits | $0 Copay | ||
| Specialist Visits | $30 Copay | ||
| Urgent Care | $40 Copay | ||
| Emergency Room Care | $90 Copay | ||
| Inpatient Hospital Care | $175 Per Day for Days 1-10; $0 Per Day for Days 11-90 (per admit) | ||
| Outpatient Hospital Surgery | $250 Copay | ||
| Maximum Out-of-Pocket Limit | $4,100 Per Year | ||
Reliance (HMO-POS) Prescription Drug Benefits* |
|||
|---|---|---|---|
| Deductible | $0 prescription drug deductible | ||
| Preferred Retail and Mail-Order Cost-Sharing | |||
| Tier | One-Month Supply | Two-Month Supply | Three-Month Supply |
| Tier 1 (Preferred Generics) | $0 copay | $0 copay | $0 copay |
| Tier 2 (Generics) | $12 copay | $24 copay | $36 copay |
| Tier 3 (Preferred Brand)** | $45 copay | $90 copay | $135 copay |
| Tier 4 (Non-Preferred Drug) | $100 copay | $200 copay | $300 copay |
| Tier 5 (Specialty) | 33% coinsurance | Not offered | Not offered |
| Standard Retail and Mail-Order Cost-Sharing | |||
| Tier | One-Month Supply | Two-Month Supply | Three-Month Supply |
| Tier 1 (Preferred Generics) | $5 copay | $10 copay | $15 copay |
| Tier 2 (Generics) | $14 copay | $28 copay | $42 copay |
| Tier 3 (Preferred Brand)** | $47 copay | $94 copay | $141 copay |
| Tier 4 (Non-Preferred Drug) | $100 copay | $200 copay | $300 copay |
| Tier 5 (Specialty) | 33% coinsurance | Not offered | Not offered |
*For in-network pharmacies only.
**Some generics may be included on Tier 3.
Plan Features to Help Keep You Healthy |
|
|---|---|
| Flex Card |
$2,150 on a Flex Card to pay for out-of-pocket costs, including:
|
| Dental Services | Dental benefits including two dental cleanings and two exams per year covered at no cost (total allowance of $2,200 combined preventive and comprehensive dental services). Can use allowance amount toward dentures. |
| Vision Services | No-cost routine eye exam (up to 1 every year) with the freedom to choose from hundreds of participating providers and retailers, plus $450 to spend on eyewear via Flex Card. |
| Hearing Services | $0 copay for routine hearing exam (up to 1 every year), plus $1,100 to spend on prescription hearing aids via Flex Card. |
| Fitness Benefit | No-cost fitness center membership or home fitness kits |
| Over-the-Counter Health-Related Products | $600 ($150 available per quarter) via Flex Card for over-the-counter health-related products that you can purchase at major retailers or online |
* For in-network services only, where applicable. Retailer restrictions may apply.
The Silver&Fit Program is provided by American Specialty Health Fitness Inc., a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit is a registered trademark of ASH and used with permission herein. All programs and services are not available in all areas.
Click below to search for Hospitals or Medical Providers in the Vantage Network.
