Customer Service 800.722.1471
Group Number: 4024205
Any deductibles, copays, and coinsurance percentages shown are amounts for which you're responsible. Medical Benefits apply after the calendar-year deductible is met unless otherwise noted, or if the cost share is a copay.
PREMERA PREFERRED CHOICE: PPO - $1,000/20%/50%/$5,000/$25 - HERITAGE
| MEDICAL COST SHARE OPTIONS | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Individual Deductible PCY (Family embedded deductible 2X Individual) | $1,000 | $2,000 |
| Coinsurance (Member's percentage of costs after deductible based on allowable charges) | 20% | 50% |
| Individual Out of Pocket Maximum PCY, includes deductible, coinsurance, copay and pharmacy if applicable (Family embedded OOP max 2X Individual) | $4,500 | $9,000 (2x family max) |
| Office Visit Cost Share | $25 Copay, applies to the $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| PREVENTIVE CARE OPTIONS AND HEALTH EDUCATION | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Preventive Office Visit (Unlimited, subject to standard medical guidelines) | Covered in Full | Not Covered |
| Immunizations (Unlimited, subject to standard medical guidelines) | Covered in Full | Not Covered |
| Health Education (HE) (Unlimited) | Covered in Full | Not Covered |
| Nicotine Dependency Programs (ND) (Unlimited) | Covered in Full | Not Covered |
| Diabetes Health Education (DE) (Unlimited)Diabetes Health Education (DE) (Unlimited) | Covered in Full | Not Covered |
| PROFESSIONAL CARE | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Professional Office Visit | $25 Copay, applies to the $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Telemedicine with Traditional Providers - General Medical | $10 Copay, applies to the $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| VIRTUAL CARE SERVICES | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Telemedicine - General Medical (Virtual Care Only) | $1O Copay, applies to the $5,000 Out of Pocket Maximum | Not Covered |
| Telemedicine - Mental Health (Virtual Care Only) | Subject to Mental Health Outpatient Professional Care In-Network Cost Share | Not Covered |
| Telemedicine - Chemical Dependency (Virtual Care Only) | Subject to Chemical Dependency Outpatient Office Visit | Not Covered |
| DIAGNOSTIC SERVICE OPTIONS | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Preventive Professional Diagnostic Imaging and Laboratory Services - Including Mammogram and PAP/PSA | Covered in Full | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Other Professional Diagnostic Imaging | Waive Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Professional Diagnostic Major Imaging | Waive Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Other Professional Diagnostic Laboratory/Pathology | Waive Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Diagnostic Mammography | Waive Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| FACILITY CARE OPTIONS | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Inpatient Facility | $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Inpatient Professional Services | $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Outpatient Surgery Facility | $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Skilled Nursing Facility (60 days PCY; includes room and board, and facility billed professional and ancillary fees) | $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| HOSPICE & HOME HEALTH CARE | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Hospice Inpatient Facility (10 days Inpatient; within the 6 month lifetime maximum) | $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Hospice Care (Hospice Home Visits Unlimited; Respite: 240 hours; within the 6 month lifetime maximum) | $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| MATERNITY & REPRODUCTIVE CARE | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Contraceptive Management Services (Unlimited) | Covered in Full | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Sterilization - Female (Unlimited) | Covered in Full | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Sterilization - Male (Unlimited) | Covered in Full | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| PREMERA DESIGNATED CENTERS OF EXCELLENCE | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Centers of Excellence Packaged Services (Eligible Services Include: Total Joint Replacement (Knee & Hip Replacement)) | Covered in Full | Covered as any other service |
| Centers of Excellence for Radiology (Member Outreach Included) | Covered as any other service | Covered as any other service |
| MEDICAL TRANSPORTATION BENEFITS | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Centers of Excellence Travel and Care Coordination (Limited to IRS Guidelines) | Covered in Full | Covered in Full |
| EMERGENCY CARE AND TRANSPORTATION OPTION | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Emergency Care (If applicable, waive copay if admitted to inpatient facility) | $150 Copay then $1,000 Deductible and 20% Coinsurance; all cost shares apply to the $5,000 Out of Pocket Maximum | $150 Copay then $1,000 Deductible and 20% Coinsurance; all cost shares apply to the $5,000 Out of Pocket Maximum |
| Emergency Room Physician | $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum | $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum |
| Urgent Care Center | $25 Copay, applies to the $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Ambulance Transportation (Unlimited) | $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum | $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum |
| ALTERNATIVE CARE | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Acupuncture (12 visits PCY) | $25 Copay, applies to the $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Manipulations (Spinal and other) (12 visits PCY) | $25 Copay, applies to the $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| CHEMICAL DEPENDENCY & MENTAL HEALTH | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Chemical Dependency Inpatient Facility Care (Unlimited) | $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Chemical Dependency Outpatient Professional Care (Unlimited) | $25 Copay, applies to the $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Mental Health Inpatient Facility Care (Unlimited) | $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Mental Health Outpatient Professional Care (Unlimited) | $25 Copay, applies to the $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| REHABILITATION & NEURO | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Rehab Inpatient Facility (30 days PCY) | $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Rehab Outpatient Care, Including Physical, Occupational, Speech and Massage Therapy, and Chronic Pain (up to 45 visits PCY / limitations apply, see contract for details- carrier approval required) | $25 Copay, applies to the $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Rehab Outpatient Care Chronic Conditions, Including Cardiac, Pulmonary Rehab, and Cancer | $25 Copay, applies to the $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| OTHER SERVICES | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Allergy/Therapeutic Injections | Covered in Full | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Medical Supplies, Equipment, Prosthetics (Unlimited) | $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum | $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Transplants (Unlimited; $7,500 travel and lodging limits) | Covered as any other service | Not Covered |
| SUPPLEMENTAL BENEFITS | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Routine Vision Exam (1 PCY) | $25 Copay | $25 Copay |
| Vision Hardware ($150 every 2 consecutive calendar years) | Covered in Full | Covered in Full |
| Pediatric Vision Exam (1 PCY under age 19) | $25 Copay, applies to the $5,000 Out of Pocket Maximum | $25 Copay, applies to the $5,000 Out of Pocket Maximum |
| Pediatric Vision Hardware (Under age 19 One pair of glasses PCY (frames & lenses). 12 month supply of contacts PCY, in lieu of glasses (frames & lenses).) | Covered in Full | Covered in Full |
| ANNUAL PLAN MAXIMUM | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Annual Plan Maximum | Unlimited | Unlimited |
Any deductibles, copays, and coinsurance percentages shown are amounts for which you're responsible. Medical Benefits apply after the calendar-year deductible is met unless otherwise noted, or if the cost share is a copay.
PREMERA PREFERRED CHOICE: AGG HSA - $1,600/20%/50%/$4,000/DED.COINS (MAC) HERITAGE
| MEDICAL COST SHARE OPTIONS | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Individual Deductible PCY (Family aggregate deductible 2x Individual) | $1,600/$3,200 | $3,200/$6,400 |
| Coinsurance (Member's percentage of costs after deductible based on allowable charges) | 20% | 50% |
| Individual Out of Pocket Maximum PCY, includes deductible, coinsurance, copay and pharmacy if applicable (Family embedded OOP max 2X Individual) | $4,000 | $8,000 (2x family max) |
| Office Visit Cost Share | $1,600/$3,200 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,200/$6,400 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| PREVENTIVE CARE OPTIONS AND HEALTH EDUCATION | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Preventive Office Visit (Unlimited, subject to standard medical guidelines) | Covered in Full | Not Covered |
| Immunizations (Unlimited, subject to standard medical guidelines) | Covered in Full | Not Covered |
| Health Education (HE) (Unlimited) | Covered in Full | Not Covered |
| Nicotine Dependency Programs (ND) (Unlimited) | Covered in Full | Not Covered |
| Diabetes Health Education (DE) (Unlimited) | Covered in Full | Not Covered |
| PROFESSIONAL CARE | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Professional Office Visit | $7,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Telemedicine with Traditional Providers - General Medical | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| VIRTUAL CARE SERVICES | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Telemedicine - General Medical (Virtual Care Only) | $7,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | Not Covered |
| Telemedicine - Mental Health (Virtual Care Only) | Subject to Mental Health Outpatient Professional Care In-Network Cost Share | Not Covered |
| Telemedicine - Chemical Dependency (Virtual Care Only) | Subject to Chemical Dependency Outpatient Office Visit | Not Covered |
| DIAGNOSTIC SERVICE OPTIONS | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Preventive Professional Diagnostic Imaging and Laboratory Services - Including Mammogram and PAP/PSA | Covered in Full | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Other Professional Diagnostic Imaging | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Professional Diagnostic Major Imaging | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Other Professional Diagnostic Laboratory/Pathology | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Diagnostic Mammography | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| FACILITY CARE OPTIONS | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Inpatient Facility | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Inpatient Professional Services | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Outpatient Surgery Facility | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Skilled Nursing Facility (60 days PCY; includes room and board, and facility billed professional and ancillary fees) | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| HOSPICE & HOME HEALTH CARE | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Hospice Inpatient Facility (10 days Inpatient; within the 6 month lifetime maximum) | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Hospice Care (Hospice Home Visits Unlimited; Respite: 240 hours; within the 6 month lifetime maximum) | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| MATERNITY & REPRODUCTIVE CARE | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Contraceptive Management Services (Unlimited) | Covered in Full | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Sterilization - Female (Unlimited) | Covered in Full | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Sterilization - Male (Unlimited) | Subject to the IRS Minimum Deductibles, then 0% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| PREMERA DESIGNATED CENTERS OF EXCELLENCE | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Centers of Excellence Packaged Services (Eligible Services Include: Total Joint Replacement (Knee & Hip Replacement)) | $1,500/$3,000 Deductible, 0% Coinsurance, applies to $4,000 Out of Pocket Maximum | Covered as any other service |
| Centers of Excellence for Radiology (Member Outreach Included) | Covered as any other service | Covered as any other service |
| MEDICAL TRANSPORTATION BENEFITS | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Centers of Excellence Travel and Care Coordination (Limited to IRS Guidelines) | $1,500/$3,000 Deductible, 0% Coinsurance, applies to $4,000 Out of Pocket Maximum | $1,500/$3,000 Deductible, 0% Coinsurance, applies to $4,000 Out of Pocket Maximum |
| EMERGENCY CARE AND TRANSPORTATION OPTION | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Emergency Care | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum |
| Emergency Room Physician | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum |
| Urgent Care Center | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum |
| Ambulance Transportation (Unlimited) | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum |
| ALTERNATIVE CARE | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Acupuncture (12 visits PCY) | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Manipulations {Spinal and other) (12 visits PCY) | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| CHEMICAL DEPENDENCY & MENTAL HEALTH | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Chemical Dependency Inpatient Facility Care (Unlimited) | $7,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Chemical Dependency Outpatient Professional Care (Unlimited) | $7,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Mental Health Inpatient Facility Care (Unlimited) | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | |
| Mental Health Outpatient Professional Care (Unlimited) | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| REHABILITATION & NEURO | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Rehab Inpatient Facility (30 days PCY) | $7,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Rehab Outpatient Care, Including Physical, Occupational, Speech and Massage Therapy, and Chronic Pain (45 visits PCY) | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Rehab Outpatient Care Chronic Conditions, Including Cardiac, Pulmonary Rehab, and Cancer | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| OTHER SERVICES | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Allergy/Therapeutic Injections | $7,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Medical Supplies, Equipment, Prosthetics (Unlimited) | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum | $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
| Transplants (Unlimited; $7,500 travel and lodging limits) | Covered as any other service | Not Covered |
| PHARMACY | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Prescription Drugs - Retail (Specific preventive drugs and legend Retail 90 day supply/Mail 90 day supply/Specialty 30 day supply) | $7,500/$3,000 Deductible, then 20% Coinsurance, applies to the $4,000 Out of Pocket Maximum | $7,500/$3,000 Deductible, then 20% Coinsurance, applies to the $4,000 Out of Pocket Maximum |
| Prescription Drugs - Mail (Specific preventive drugs and legend Retail: 90 day supply/Mail: 90 day supply/Specialty: 30 day supply) | $1,500/$3,000 Deductible, then 20% Coinsurance, applies to the $4,000 Out of Pocket Maximum | Not Covered |
| Drug List | Open A1 No Tiers | Open A1 No Tiers |
| Specialty Pharmacy (Mandatory- Exclusive) | $7,500/$3,000 Deductible, then 20% Coinsurance, applies to the $4,000 Out of Pocket Maximum | Not Covered |
| SUPPLEMENTAL BENEFITS | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Routine Vision Exam (1 PCY) | $25 Copay | $25 Copay |
| Vision Hardware ($150 every 2 consecutive calendar years) | Covered in Full | Covered in Full |
| Pediatric Vision Exam (1 PCY under age 19) | $25 Copay, applies to the $4,000 Out of Pocket Maximum | $25 Copay, applies to the $4,000 Out of Pocket Maximum |
| Pediatric Vision Hardware (Under age 19 One pair of glasses PCY (frames & lenses). 12 month supply of contacts PCY, in lieu of glasses (frames & lenses).) | Covered in Full | Covered in Full |
| ANNUAL PLAN MAXIMUM | HERITAGE IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Annual Plan Maximum | Unlimited | Unlimited |