Erickson Advantage Liberty no Rx (HMO-POS)

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

• • In-Network: No

Diagnostic and Preventive Dental

• Dental X-Rays
  • In-Network: No Coins – 0.00 Copay
  • Out-of-Network: No Coins – 0.00 Copay
• Fluoride Treatment
  • In-Network: No Coins – 0.00 Copay
  • Out-of-Network: No Coins – 0.00 Copay
• Oral Exams
  • In-Network: No Coins – 0.00 Copay
  • Out-of-Network: No Coins – 0.00 Copay
• Other Preventive Dental Services
  • In-Network: No Coins – 0.00 Copay
  • Out-of-Network: No Coins – 0.00 Copay
• Prophylaxis (cleaning)
  • In-Network: No Coins – 0.00 Copay
  • Out-of-Network: No Coins – 0.00 Copay

Diagnostic procedures/lab services/imaging

• Diagnostic radiology services (e.g., MRI)
  • Out-of-Network: 40% coinsurance (Authorization Required)
• Lab services
  • In-Network: $0 copay (Authorization Required)
  • Out-of-Network: $0 copay (Authorization Required)
• Outpatient x-rays
  • In-Network: $25 copay (Authorization Required)
  • Out-of-Network: $40 copay (Authorization Required)
• Diagnostic tests and procedures
  • Out-of-Network: 40% coinsurance (Authorization Required)
• Diagnostic radiology services (e.g., MRI)
  • In-Network: $0-225 copay (Authorization Required)
• Diagnostic tests and procedures
  • In-Network: $50 copay (Authorization Required)

Doctor visits

• Primary
  • In-Network: $0 copay
  • Out-of-Network: $50 copay per visit
• Specialist
  • In-Network: $0-60 copay per visit (Authorization Required)
  • Out-of-Network: $85 copay per visit (Authorization Required)

Emergency care/Urgent care

• Emergency
  • $125 copay per visit (always covered)
• Urgent care
  • $0-50 copay per visit (always covered)

Foot care (podiatry services)

• Foot exams and treatment
  • Out-of-Network: $85 copay (Authorization Required)
• Routine foot care
  • In-Network: $45 copay (Limits Apply, Authorization Required)
• Foot exams and treatment
  • In-Network: $45 copay (Authorization Required)

Ground ambulance

• • Out-of-Network: $275 copay
  • In-Network: $275 copay

Health plan deductible

• • $750 In-network

Hearing

• Hearing aids
  • In-Network: $199-1,249 copay (Limits Apply, Authorization Required)
• Hearing aids OTC
  • In-Network: $99-829 copay (Limits Apply)
• Medicare-Covered Hearing Exam
  • Out-of-Network: $85 copay (Authorization Required)
• Fitting/evaluation
  • Not covered
• Medicare-Covered Hearing Exam
  • In-Network: $0 copay (Authorization Required)

Inpatient hospital coverage

• • Out-of-Network: 40% per stay (Authorization Required)
  • In-Network: $375 per day for days 1 through 7
    $0 per day for days 8 through 90
    $0 per day for days 91 and beyond (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

• • $6,750 In-network
    $9,450 Out-of-network

Medical equipment/supplies

• Diabetes supplies
  • Out-of-Network: 40% coinsurance per item (Authorization Required)
• Durable medical equipment (e.g., wheelchairs, oxygen)
  • Out-of-Network: 40% coinsurance per item (Authorization Required)
• Prosthetics (e.g., braces, artificial limbs)
  • In-Network: 20% coinsurance per item (Authorization Required)
  • Out-of-Network: 40% coinsurance per item (Authorization Required)
• Diabetes supplies
  • In-Network: $0 copay per item (Authorization Required)
• Durable medical equipment (e.g., wheelchairs, oxygen)
  • In-Network: 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

• Chemotherapy
  • In-Network: 0-20% coinsurance (Authorization Required)
  • Out-of-Network: 40% coinsurance (Authorization Required)
• Other Part B drugs
  • In-Network: 0-20% coinsurance (Authorization Required)
  • Out-of-Network: 0-40% coinsurance (Authorization Required)

Mental health services

• Outpatient group therapy visit
  • Out-of-Network: 40% coinsurance (Authorization Required)
• Outpatient group therapy visit with a psychiatrist
  • Out-of-Network: 40% coinsurance (Authorization Required)
• Outpatient group therapy visit
  • In-Network: $0 copay (Authorization Required)
• Outpatient individual therapy visit
  • In-Network: $0-30 copay (Authorization Required)
• Outpatient individual therapy visit with a psychiatrist
  • Out-of-Network: 40% coinsurance (Authorization Required)
• Inpatient hospital – psychiatric
  • Out-of-Network: 40% per stay (Authorization Required)
• Outpatient group therapy visit with a psychiatrist
  • In-Network: $0 copay (Authorization Required)
• Inpatient hospital – psychiatric
  • In-Network: $375 per day for days 1 through 6
    $0 per day for days 7 through 90 (Authorization Required)
• Outpatient individual therapy visit
  • Out-of-Network: 40% coinsurance (Authorization Required)
• Outpatient individual therapy visit with a psychiatrist
  • In-Network: $0-30 copay (Authorization Required)

Optional supplemental benefits

• • Yes

Other health plan deductibles?

• • In-Network: No

Outpatient hospital coverage

• • Out-of-Network: 40% coinsurance per visit (Authorization Required)
  • In-Network: $0-375 copay per visit (Authorization Required)

Preventive care

• • In-Network: $0 copay
  • Out-of-Network: 0-40% coinsurance

Rehabilitation services

• Occupational therapy visit
  • In-Network: 0-20% coinsurance (Authorization Required)
  • Out-of-Network: 40% coinsurance (Authorization Required)
• Physical therapy and speech and language therapy visit
  • Out-of-Network: 40% coinsurance (Authorization Required)
  • In-Network: 0-20% coinsurance (Authorization Required)

Skilled Nursing Facility

• • In-Network: $0 per day for days 1 through 20
    $203 per day for days 21 through 100 (Authorization Required)
  • Out-of-Network: 40% per stay (Authorization Required)

Transportation

• • Not covered

Vision

• Contact lenses
  • In-Network: $0 copay (Limits Apply)
• Other
  • Not covered
• Routine eye exam
  • In-Network: $0 copay (Limits Apply, Authorization Required)
• Eyeglass frames
  • In-Network: $0 copay (Limits Apply)
• Eyeglass lenses
  • In-Network: $0-153 copay (Limits Apply)
• Eyeglasses (frames and lenses)
  • Not covered
• Routine eye exam
  • Out-of-Network: $85 copay (Limits Apply, Authorization Required)
• Upgrades
  • Not covered

Wellness programs (e.g., fitness, nursing hotline)

• • Covered

Dental Platinum Rider

Comprehensive Dental

• Restorative Services, Endodontics, Periodontics, Prosthodontics, removable, Maxillofacial Prosthetics, Prosthodontics, fixed, Oral and Maxillofacial Surgery, Adjunctive General Services
  • Monthly Premium: $54.00

Diagnostic and Preventive Dental

• Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Fluoride Treatment, Other Preventive Dental Services
  • Monthly Premium: $54.00

Point of Service (POS)

• POS: POS option
  • Monthly Premium: $54.00