$143 premium
$1,700 on a Flex Card to pay for out-of-pocket costs, including:
$1,100 to pay for prescription hearing aids
$400 to pay for eyewear like eyeglasses and contact lenses from your choice of hundreds of participating providers and retailers
$200 ($50 available per quarter) for over-the-counter items 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 deductible for prescription drugs
$0 copay for up to a 3-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
In-Network Medical |
|||
|---|---|---|---|
| PPO | |||
| Premium | $143 Per Month | ||
| Medical Deductible | $0 Per Year for In-Network Covered Services | ||
| Preventive Care | $0 Copay | ||
| Primary Care Visits | $0 Copay | ||
| Specialist Visits | $40 Copay | ||
| Urgent Care | $35 Copay | ||
| Emergency Room Care | $125 Copay | ||
| Inpatient Hospital Care | $170 Per Day for Days 1-10; $0 Per Day for Days 11-90 (per admit) | ||
| Outpatient Hospital Surgery | $200 Copay | ||
| Maximum Out-of-Pocket Limit | $4,000 Per Year | ||
Premier (PPO) 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) | 50% coinsurance | 50% coinsurance | 50% coinsurance |
| 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) | $10 copay | $20 copay | $30 copay |
| Tier 2 (Generics) | $18 copay | $36 copay | $54 copay |
| Tier 3 (Preferred Brand)** | $47 copay | $94 copay | $141 copay |
| Tier 4 (Non-Preferred Drug) | 50% coinsurance | 50% coinsurance | 50% coinsurance |
| 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 |
$1,700 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, plus $400 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 studio/gym membership, plus digital fitness and wellness content |
| Over-the-Counter Items | $200 ($50 available per quarter) via Flex Card for over-the-counter items that you can purchase at major retailers or online |
* For in-network services only, where applicable. Retailer restrictions may apply.
Click below to search for Hospitals or Medical Providers in the Vantage Network.
