| New! |
| VIP Plus (HMO) | VIP (HMO) | Gold (HMO) | Platinum (HMO) |
Plan overview
|
Monthly plan premium | $0 | $0 | $0 | $62 |
Deductible (medical) | $0 | $0 | $0 | $0 |
Deductible (pharmacy) | $350, Tiers 4 & 5 |
Annual out-of-pocket maximum | $2,900 yearly limit for services you receive from in-network providers |
Doctor visits
|
Primary care physician visit | $0 | $0 | $5 | $5 |
Specialist visit | $0 | $0 | $20 | $20 |
Preventive care | $0 | $0 | $0 | $0 |
Lab services / X-rays | $0 / $10 | $0 / $10 | $0 / $10 | $0 / $0 |
Diagnostic radiology services (e.g., MRIs) | $75 copay
$0 for diagnostic mammogram | $75 copay
$0 for diagnostic mammogram | $75 copay
$0 for diagnostic mammogram | 15% coinsurance
$0 for diagnostic mammogram |
Physical therapy | $30 | $30 | $30 | $30 |
Outpatient rehabilitation | $30 | $30 | $30 | $30 |
Hospital visits and emergencies
|
Inpatient hospital coverage | $225/day for days 1–7 $0/day for days 8+ | $250/day for days 1–7
$0/day for days 8+ | $250/day for days 1–7
$0/day for days 8+ | $200/day for days 1–8 $0/day for days 9+ |
Outpatient hospital coverage | $0–$100 | $0–$120 | $20–$225 | $20–$175 |
Emergency care | $150 | $150 | $150 | $150 |
Urgently needed services | $30 ($150 for worldwide urgent care and emergency coverage) |
Supplemental benefits
|
Hearing aids | $4,000 allowance every 36 months | $3,800 allowance every 36 months | $4,000 allowance every 36 months | $4,800 allowance every 36 months |
Silver&Fit® Fitness Benefit | $0 | $0 | $0 | $0 |
Chiropractic care | $10, limit 30 visits per year (combined) | $10, limit 30 visits per year (combined) | $10, limit 30 visits per year (combined) | $10, limit 30 visits per year (combined) |
Acupuncture |
Over-the-counter (OTC) items Available on a pre-loaded debit card | Up to $160 per quarter | Up to $140 per quarter | Up to $140 per quarter | Up to $180 per quarter |
Dental |
Delta Dental DHMO | $0 monthly premium | $0 monthly premium | $13 monthly premium | $0 monthly premium |
Delta Dental PPO | $55 monthly premium | $55 monthly premium | $55 monthly premium | $55 monthly premium |
Vision |
Frames or Contacts
| $400 (every 12 months) | $300 (every 12 months) | $300 (every 12 months) | $300 (every 12 months) |
Routine eye exam | $0 (every 12 months) | $0 (every 12 months) | $0 (every 12 months) | $0 (every 12 months) |
Medicare Part D drugs: initial coverage
|
Retail: 1-month supply |
Tier 1 (Preferred Generic) | $2 |
Tier 2 (Generic) | $8 |
Tier 3 (Preferred Brand) | $40 |
Tier 4 (Non-preferred Brand) | $90 |
Tier 5 (Specialty) | 29% of the cost |
Tier 6 (Select Care)
| $0 |
Mail order: 100-day supply
|
Tier 1 (Preferred Generic) | $0 |
Tier 2 (Generic) | $0
|
Tier 3 (Preferred Brand) | $80 |
Tier 4 (Non-preferred Brand) | $180
|
Tier 5 (Specialty) | Not offered |
Tier 6 (Select Care)
| $0 |