Plan 1 & 2 – GA Insurance Hub

Medical Plan Options	Plan 1	Plan 2
Evidence of insurability	Guaranteed Acceptance
PPO Network	First Health®
Deductible	In-Network Provider (No Out of Network Coverage)
Individual/ Family	n/a	$2,000/$4,000
Out-of-Pocket Max
Individual/ Family	$9,200/$18,400	$9,200/$18,400
Medical Services
Preventive & Wellness Services (Non-Hospital Based)	$0 Copay (Plan pays 100% of covered preventive and wellness services)
Primary Care Office Visit (Non-Hospital Based)	$25 Copay (Combined visit of 5 visits/plan yr)	$25 Copay per visit (Deductible does not apply)
Specialist Office Visit (Non-Hospital Based)		$50 Copay per visit (Deductible does not apply)
Urgent Care		$50 Copay per visit (Deductible does not apply)
Telemedicine Services	$0 Copay3
Outpatient Diagnostic Services
Laboratory Services (Non-Hospital Based)	$25 Copay (Combined limit of 5 visits/plan yr)	$50 Copay per panel tested or image billed (Deductible does not apply)
Radiology (Non-Hospital Based)	$25 Copay (Combined limit of 5 visits/plan yr)
CT/MRI/PET Scan (Non-Hospital Based)	Not Covered	50% Coinsurance after Deductible1
Pregnancy Benefits
Office Visits	$25 Copay (Considered a Specialist Office Visit.)	$50 Copay (Considered a Specialist Office Visit.) (Deductible does not apply)
Mental Health, Behavioral Health, or Substance Abuse Services
Inpatient or Partial Day	Not Covered
Outpatient Hospital or Free-Standing Facility Services and Surgery	Not Covered
Office Visits	$25 Copay (Combined limit of 5 visits/plan yr)	$25 Copay per visit (Deductible does not apply)
Other Services
Rehabilitation/Habilitation Services (Physical, Speech, and Occupational)	Not Covered	$50 Copay per visit (Combined limit of 20 visits/plan yr.) (Pre-Authorization is required after 6 visits.)
PHARMACY BENEFITS – Included in Medical Plans
Preventive Prescriptions	No Copay for ACA Compliant covered prescription drugs
Non-Preventive Prescriptions	20% Coinsurance – Generic Only 12 Prescriptions Maximum30 day supply Maximum 30 day supply Maximum	$20 Copay – Generic only 30 day supply Maximum
30 day supply Maximum

PHARMACY BENEFITS – Provided by DataRX2
Prescription Benefit	Not Covered	Copay: $10 Formulary Generic; $50 Formulary Brand Mail Copay: $30 Formulary Generic; $150 Formulary Brand Annual Max: $750 Per Person; $1500 Per Family

Preventative and Wellness Services – Covered Benefits

Abdominal aortic aneurysm screening	Depression screening	Lung cancer screening
Alcohol misuse screening and counseling	Diabetes screening	Obesity screening and counseling
	Falls prevention: exercise or physical
Aspirin: preventative medication	therapy	Osteoporosis screening
Bacteriuria screening	Falls prevention: vitamin D	Phenylketonuria screening
	supplementation
Blood pressure screening	Folic acid supplementation	Preeclampsia screening
BRCA risk assessment and genetic	Gestational diabetes mellitus screening	Rh incompatibility screening: first
counseling/testing		pregnancy visit
Breast cancer prevention medications	Gonorrhea prophylactic medication	Rh incompatibility screening: 24-28 weeks’
		gestation
Breast cancer screening	Gonorrhea screening	Sexually transmitted infections counseling
	Healthy diet and physical activity
Breastfeeding interventions	counseling to prevent cardiovascular	Skin cancer behavioral counseling
	disease
Cervical cancer screening: with cytology
(Pap smear)	Hemoglobinopathies screening	Statin preventive medication
Cervical cancer screening: with
combination of cytology and human	Hepatitis B screening	Tobacco use counseling and interventions
papillomavirus (HPV) testing
Chlamydia screening	Hepatitis C virus (HCV) infection screening	Tuberculosis screening
Colorectal cancer screening	HIV screening	Syphilis screening
Contraceptive methods and counseling	Hypothyroidism screening	Vision screening
Dental cavities prevention: infants and	Intimate partner violence screening	Well-woman visits
Preventative and Wellness Services – Covered Benefits

Abdominal aortic aneurysm screening	Depression screening	Lung cancer screening
Alcohol misuse screening and counseling	Diabetes screening	Obesity screening and counseling
	Falls prevention: exercise or physical
Aspirin: preventative medication	therapy	Osteoporosis screening
Bacteriuria screening	Falls prevention: vitamin D	Phenylketonuria screening
	supplementation
Blood pressure screening	Folic acid supplementation	Preeclampsia screening
BRCA risk assessment and genetic	Gestational diabetes mellitus screening	Rh incompatibility screening: first
counseling/testing		pregnancy visit
Breast cancer prevention medications	Gonorrhea prophylactic medication	Rh incompatibility screening: 24-28 weeks’
		gestation
Breast cancer screening	Gonorrhea screening	Sexually transmitted infections counseling
	Healthy diet and physical activity
Breastfeeding interventions	counseling to prevent cardiovascular	Skin cancer behavioral counseling
	disease