Page 12 - NAPA 2021-2022

BlueChoice Plus Gold 500 Summary of Benefits

Services In-Network You Pay 1 Out-of-Network You Pay 1
DIAGNOSTIC SERVICES​
Labs 9​ ​ ​
■ Non-Hospital/Freestanding Facility​ $15 per visit (LabCorp only)​ Deductible, then $65 per visit​
■ Hospital​ Deductible, then $30 per visit​ Deductible, then $110 per visit​
(preauthorization required)​
X-ray 9​ ​ ​
■ Non-Hospital/Freestanding Facility​ $30 per visit​ Deductible, then $80 per visit​
■ Hospital​ Deductible, then $60 per visit​ Deductible, then $110 per visit​
(preauthorization required)​
Imaging 9​ ​ ​
■ Non-Hospital/Freestanding Facility​ $200 per visit​ Deductible, then $250 per visit​
■ Hospital​ Deductible, then $400 per visit​ Deductible, then $450 per visit​
(preauthorization required)​
SURGERY AND HOSPITALIZATION—(Members are responsible for both physician and facility fees)​
Outpatient Surgery (Non-Hospital)​ ​ ​
■ Facility​ $200 per visit​ Deductible, then $300 per visit​
■ Physician​ $30 per visit​ Deductible, then $50 per visit​
Outpatient Surgery (Hospital)​ ​ ​
■ Facility​ Deductible, then $300 per visit​ Deductible, then $400 per visit​
■ Physician​ Deductible, then $30 per visit​ Deductible, then $50 per visit​
Inpatient Surgery and Hospital Services​ ​ ​
■ Facility​ Deductible, then $400 per admission​ Deductible, then $500 per admission​
■ Physician​ Deductible, then $30 per visit​ Deductible, then $50 per visit​
HOSPITAL ALTERNATIVES​
Home Health Care​ No charge*​ Deductible, then $50 per visit​
Hospice​ No charge*​ Deductible, then $50 per admission​
Skilled Nursing Facility​ Deductible, then $30 per admission​ Deductible, then $50 per admission​
(limited to 100 days/benefit period)​
MATERNITY​
Preventive Prenatal and Postnatal Office Visits​ No charge*​ Deductible, then $50 per visit​
Delivery and Facility Services​ Deductible, then $400 per admission​ Deductible, then $500 per admission​
Artificial and Intrauterine Insemination 6,10​ Deductible, then $15 per visit​ Deductible, then $50 per visit​
In Vitro Fertilization Procedures 6,10​ Not covered​ Not covered​
MENTAL HEALTH AND SUBSTANCE USE DISORDER—(Members are responsible for both physician and facility fees)​
Office Visits​ $15 per visit​ Deductible, then $50 per visit​
Outpatient Services​ ​ ​
■ Facility​ $50 per visit​ Deductible, then $50 per visit​
■ Physician​ $30 per visit​ Deductible, then $50 per visit​
Inpatient Services​ ​ ​
■ Facility​ Deductible, then $400 per admission​ Deductible, then $500 per admission​
■ Physician​ Deductible, then $30 per visit​ Deductible, then $50 per visit​
MEDICAL DEVICES AND SUPPLIES​
Durable Medical Equipment​ Deductible, then 25% of Allowed Benefit​ Deductible, then 45% of Allowed Benefit​
Hearing Aids​ Deductible, then 25% of Allowed Benefit​ Deductible, then 45% of Allowed Benefit​
(limited to one hearing aid per​
hearing-impaired ear every 36 months)​

SUM5160-1P (1/21) ■ MD ■ 2021 2-50 ACA Compliant​