Medical Plan Options | Plan 3 | Plan 4 | Plan 5 |
Evidence of insurability | Guaranteed Acceptance | ||
PPO Network8 | MultiPlan®: PHCS; Practitioner & Ancillary | ||
Deductible | In-Network Provider | ||
Individual/ Family | $0 | $9,200/$18,400 | $5,000/$10,000 |
Out-of-Pocket Max | In-Network Provider | ||
Individual/ Family | $9,200/$18,400 | $9,200/$18,400 | $9,200/$18,400 |
Medical Services | In-Network Provider | ||
Preventive & Wellness (Non-Hospital Based) | $0 Copay (Plan pays 100% of covered preventive and wellness services) | ||
Primary Care Office Visit (Non-Hospital Based) | $25 Copay | $25 Copay | |
$60 Copay (Max 6 visits/plan yr) | |||
Specialist Office Visit (Non-Hospital Based) | $45 Copay | $45 Copay | |
Urgent Care | $50 Copay | $60 Copay | $60 Copay |
Other Physician Services Performed in the Office | $60 Copay (Combined limit with Primary Care/ Specialist visit plan yr) | $45 Copay | $45 Copay |
Telemedicine Services | $0 Copay6 | $0 Copay for Virtual Visits7 | $0 Copay6 |
Outpatient Diagnostic Services | |||
Laboratory Services (Non-Hospital Based) | |||
$50 Copay (Combined 3 visits/plan yr) | After Deductible, plan pays 100% | After Deductible, 20% coinsurance | |
Radiology (Non-Hospital Based) | |||
CT/MRI/PET Scan (Non-Hospital Based) | $350 Copay2,4 (Max of 1/plan yr) | After Deductible, plan pays 100%2,4 | After Deductible, 20% coinsurance2,4 |
Hospitalization and Emergency Services | |||
Inpatient Hospitalization2 | $350 Copay per admission2,4 (Max 3 days/plan yr) | After Deductible, plan pays 100%2 | After Deductible, 20% coinsurance4 |
Inpatient Surgery | Included in Inpatient Hospitalization Copay2,4 (Second surgical opinion may be required; Max 2 surgeries/plan yr | Included in Inpatient Hospitalization benefit | |
Outpatient Hospital or Free Standing Facility Services and Surgery2 | $350 Copay4 (Max 1 visit/plan yr) | After Deductible, plan pays 100%4 | |
Emergency room services | $350 Copay4 (Max 1 visit/plan yr) | After Deductible, 20% coinsurance4 | |
Anesthesia | Included in Inpatient Hospitalization or Outpatient Hospital or Free Standing Facility Services and Surgery Copay (Limited to 2 inpatient & 1 outpatient anesthetic procedures/plan yr) | Included in Inpatient Hospitalization or Outpatient Hospital or Free Standing Facility Services and Surgery Benefit | |
Pregnancy Benefits | |||
Office Visits | Not Covered | $25 Copay per visit | |
Professional Services | |||
Maternity/Childbirth/Delivery2 | After Deductible, plan pays 100%4 | After Deductible, 20% coinsurance4 | |
Mental Health, Behavioral Health, or Substance Abuse Services | |||
Inpatient or Partial Day2 | $350 Copay per admission2,4 (Max 3 days/plan yr) | After Deductible, plan pays 100%4 | After Deductible, 20% coinsurance4 |
Outpatient Hospital or Free-Standing Facility | $350 Copay4 (Max 1 visit/plan yr) | After Deductible, 20% coinsurance | |
Office Visits | $60 Copay (Limited to 6 visits/plan yr) | $45 Copay | $45 Copay |
Other Services | |||
Rehabilitation/Habilitation Services (Physical, Speech, and Occupational) | $50 Copay (Combined max 6 days/plan yr with physical, speech, & occupational therapies) | $45 Copay per visit (Combined limit to 20 Visits/plan yr. Pre-authorization is required after 6 visits.) | |
Allergy Services3 | $25 Copay | After Deductible, plan pays 100% | After Deductible, 20% coinsurance (max 20 visits/plan yr) |
Emergency Medical Transportation2 | $250 Copay (By land only; Max 1 transport/plan yr) | After Deductible, 20% coinsurance | |
Home Health Care | $25 Copay4 (Max 5 visits/plan yr) | After Deductible, plan pays 100%4 (Limited to 60 Visits/plan yr) | After Deductible, 20% coinsurance4 (Max 60 visits/plan yr) |
Second Surgical Opinion | $0 Copay | $0 Copay4 | |
Chiropractic Services | Not Covered | $45 Copay per visit (Limited to 20 Visits/plan yr) | $45 Copay per visit (Limited to 20 visits/plan year) |
Hospice Care | After Deductible, plan pays 100%2,4 | After Deductible, 20% coinsurance2,4 | |
Prosthetic and Orthotic devices | After Deductible, plan pays 100% (Limited to a maximum of $6,500 per plan year) | After Deductible, 20% coinsurance (max of $6,500/plan yr) | |
Skilled Nursing Facility2 | After Deductible, plan pays 100%4 (Limited to 60 days/plan yr) | After Deductible, 20% coinsurance4 (Max 60 days/plan yr) | |
Durable Medical Equipment2 | After Deductible, plan pays 100% (Subject to limitations) | After Deductible, 20% coinsurance (Subject to limitations) | |
PHARMACY BENEFITS – Included in Medical Plans | |||
Preventive Prescriptions | No Copay for ACA Compliant covered prescription drugs | ||
Non-Preventive Prescriptions | Generic – $10 Copay | Not Covered | $10 Copay – Generic only $45 Copay- Preferred Brand $100 Copay- Non-Preferred Brand |
PHARMACY BENEFITS – Provided by DataRX5 | |||
Prescription Benefit | Copay: $10 Formulary Generic; $50 Formulary Brand Annual Max: $750 Per Person; $1500 Per Family Mail Copay: $30 Formulary Generic; $150 Formulary Brand | Not Covered | |
Not available in Alaska, Hawaii, Massachusetts, and New Hampshire.
1. Combined 5 visits per year includes Primary Care Visit to Treat Injury or Illness, Specialist Visit and Urgent Care
Visit.
2. Subject to Reference Based Pricing
3. Included in Primary Care Office Visit or Specialist Office Visit limits. The copay applies to the administration of the
allergy service and is separate from the copay for the office visit
4. Pre-authorization required.
5. Prescription Benefit is offered through AC&A Limited Partnership by DataRx and is not integrated with the health
plan design. The prescription provided by DataRx is not available in NY, SD, and WA. For the Max plan only: In the
states noted, $20 co-pay generic only, 30 day supply max.
6. This benefit is offered through Galileo and is not integrated with the health plan design.
7. This benefit is offered by Galileo and is not integrated with the health plan design.
8. To find a provider through the PHCS Practitioner and Ancillary: https://www.multiplan.com/webcenter/portal/
ProviderSearch
9. The Value, Copper, and Bronze Pro plans have a 30 day waiting period applied to all benefits. Review details for
more information.
For additional information reference the Summary Plan Document for a list of services offered In-Network and out-ofNetwork. Refer to the schedule of benefits for a more in-depth list of Benefits Coverage, Limitations and Exclusions. If
this document differs from the Schedule of Benefits, the Schedule of Benefits will govern.
This coverage is available when you join the Limited Partnership. Partners must be active to maintain eligibility.
| Preventive Health Services: Limitations, Intervals, and Requirements | ||
| The following table represents the preventive services currently covered under the Pro, Max, Essential, Bronze Plans as well as the permitted interval and any requirements of such preventive services. | ||
| Benefits are automatically subject to 29 CFR § 2590.715 -2713(a). Amendments to this section through legislative act or regulation are automatically incorporated into this document by reference. Preventive Services covered in this section are explained in more detail through the following official resources: • Medical services with a rating of “A” or “B” from the current recommendations of the United States Preventive Services Task Force. See https://www.uspreventiveservicestaskforce.org • Preventive care and screenings for infants, children, and adolescents provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Guidelines can be found in https://www.hrsa.gov • Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention for certain individuals only. See https://www.cdc.gov/vaccines/acip | ||
| Adults • Adult Annual Standard Physical • Alcohol Misuse: Unhealthy Alcohol Use Screening and Counseling • Aspirin: Preventive Medication • Blood pressure screening • Breastfeeding interventions • Chlamydia screening • Colorectal Cancer Screening • Dental cavities prevention: infants and children up to age 5 years • Depression Screening • Diabetes Screening • Fall Prevention: Older Adults • Healthy Diet and Physical Activity Counseling to Prevent Cardiovascular Disease • Hemoglobinopathies screening • Hepatitis B screening • Hepatitis C virus (HCV) infection screening: born between 1945 and 1965. • High Blood Pressure Screening • HIV Preexposure Prophylaxis for the Prevention of HIV Infection • HIV Screening • Hypothyroidism screening • Lung Cancer Screening • Obesity screening and Counseling • Sexually Transmitted Infections Counseling • Skin Cancer Behavioral Counseling • Statin Preventive Medication • Tobacco Use Counseling and Interventions • Syphilis Screening | Men • Abdominal aortic aneurysm screening Women • Aspirin: Preventive Medication • BRCA risk assessment and genetic counseling/ testing • Breast Cancer Preventive Medications • Breast Cancer Screening • Cervical Cancer Screening: with Cytology (Pap Smear) Lung cancer screening • Chlamydia Screening • Contraceptive Methods and Counseling • Folic Acid Supplementation • Gonorrhea Screening • Intimate Partner Violence Screening • Osteoporosis Screening • Well-Woman Visits Pregnant Women • Bacteriuria Screening • Breastfeeding Support, Supplies and Counseling • Depression Screening • Gestational Diabetes Mellitus Screening • Hepatitis B Screening • HIV Screening • Preeclampsia Screening • Rh Incompatibility Screening: First Pregnancy Visit • RH Incompatibility Screening: 24–28 Weeks’ Gestation • Syphilis Screening • Tobacco Use Counseling and Interventions | Newborns • Gonorrhea Prophylactic Medication • Hemoglobinopathies Screening • Hypothyroidism Screening • Phenylketonuria Screening Infants • Dental Caries Prevention: Infants and Children Up to Age 5 Children • Dental Caries Prevention: Infants and Children Up to Age 5 • Obesity screening and Counseling • Skin Cancer Behavioral Counseling • Tobacco Use Counseling and Interventions • Vision Screening: Age 3 to 5 • Well-Child Visits Adolescents • Depression Screening • Hepatitis B Screening • HIV Screening • Obesity screening and Counseling • Sexually Transmitted Infections Counseling • Skin Cancer Behavioral Counseling • Tobacco Use Counseling and Interventions Multiple Populations • Tuberculosis Screening: all populations at risk • Skin Cancer Behavioral Counseling: young adults, adolescents, children, and parents of young children |
| *See Schedule of Benefits for Limitations, Intervals and Requirements. | ||
| Vaccines | ||
| IMMUNIZATIONS – recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention for routine use in children, adolescents, or adults* | ||
| Adults 19 Years or Older | Children From 7 Through 18 Years Old | Birth Through 6 Years Old |
| • IIV • RIV • LAIV • Tdap • MMR • VAR • RZV • ZVL • HPV – Female • HPV- Male • PCV13 • PPSV23 | • Flu • Tdap • HPV • MenACWY • MenACWY | • HepB • DTaP • Hib • PCV13 • IPV • Flu • MMR • VAR • HepA • RV |