Health Plans Comparison Chart

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1 Health Plans Comparison Chart PPO Deductible Coinsurance (Plan pays) Annual Out-of-Pocket Maximum (Medical) (all medical s, deductibles and coinsurance for covered services will apply. Once limit is met, the Plan pays 100% of covered in-network medical expenses) Provisions Employee: $300 EE + 1: $500 Family $800 Out-of-network: Employee: $600 EE + 1: $1,200 Family $1,800 90% Out-of-network: 70% Employee: $1,500 EE + 1: $2,000 Family $3,000 Out-of-network: Employee: $4,000 EE + 1: $6,000 Family $8,000 Employee: None EE + 1: None Family: None 100% Employee: $2,500 EE + 1: $7,500 Family: $7,500 Annual Out-of-Pocket Maximum (Prescription Drugs) (all s, deductibles and coinsurance for covered services will apply. Once limit is met, the of covered in-network prescription drug expenses) Note: The medical out-of-pocket maximum is not integrated with the prescription drug out-of-pocket maximum Employee: $1,500 EE + 1: $2,000 Family $3,000 Out-of-network: N/A Note: The prescription drug out-of-pocket maximum is not integrated with the medical out-of-pocket maximum N/A 1

2 Acupuncture Covered Services after the $30 Out-of-network: after the $30 after the $20 Limit: 30 visits per member per calendar year (combined in and out-of-network) Ambulance (in or out-of-network) Limit: 20 visits per member per calendar year (combined with Spinal Manipulation services) Durable Medical Equipment Plan pays 90% after the deductible Emergency Services after the $150 Out-of-network: after the $150 Refer to the Benefit Summary for more information after the $100 Home health care services Plan pays 90% after the deductible (Office visit applies for physician house calls) Hospice services Limit: 40 visits per member per calendar year (combined in and out-of-network) Plan pays 90% after the deductible (Office visit applies for physician house calls) Hospital stay Plan pays 90% after the $200 (per Plan pays 90% Imaging services - complex (e.g. PET scans) (may be subject to pre-authorization) Plan pays 90% after the $100 (per procedure) and after the deductible Immunizations (routine) Infertility Services (outpatient) after the $30 Plan covers ART services after the $20 for office visit and 80% for IVF 2

3 Infertility Lifetime maximum Laboratory, X-Ray and other tests (outpatient) (non-routine) Mental Health Office visits - Non preventive care Outpatient surgery - office setting $25,000 medical and $15,000 prescription drugs None Inpatient services: Plan pays 90% after the $200 (per Outpatient services: after the $20 after the $30 Plan pays 90% after the deductible Inpatient services: Plan pays 90% Outpatient services: after the $20 after the $20 after the $20 Outpatient surgery - other setting Plan pays 90% after the $100 and after the deductible Plan pays 90% Prescription drugs (Retail) (up to 30 days) Generic: after the $5 Brand Formulary: after the $30 Brand Non-Formulary: after the $50 Generic (maintenance): after the $5 Generic (other): after the $10 Brand Formulary: after the $45 Out-of-network: Plan pays 70% of prescription cost 3

4 Prescription drugs (Mail - Kaiser) (Mail Order or Maintenance Choice - Generic: after the $10 Brand Formulary: after the $60 Brand Non-Formulary: after the $100 Out-of-network: Plan pays 70% of prescription cost Generic (maintenance): after the $10 Generic (other): after the $20 Brand Formulary: after the $90 (up to 90 days) Preventive care exams/ screenings Short-term rehabilitation therapy (occupational, physical, speech) Spinal manipulation after the $30 Limit: 30 visits per calendar year (combined in and out-ofnetwork) after the $30 after the $20 after the $30 Limit: 30 visits per calendar year (combined in and out-ofnetwork) Limit: 20 visits per member per calendar year (combined with Spinal Manipulation services) Substance abuse Vision exam (routine) Inpatient services: Plan pays 90% after the $200 (per Outpatient services: after the $20 Limit: One exam every 24 months Inpatient services: Plan pays 90% Outpatient services: after the $20 4

5 Well child care Age and frequency schedules apply - refer to Benefit Summary for more details or call Member Services at Age and frequency schedules apply - refer to Benefit Summary for more details or call Member Services at The information contained in this document is intended to provide a general description of MITRE's health plans. In the event of any inconsistency between the information provided and actual policies or documents, or to the degree the actual policies or documents contain more complete or detailed information, the plan policies or documents will govern and take precedence. 5

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