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Headline: $0/$1,500 Deductible Plan with HSA

See which plan works best for you. Download a printer-friendly feature comparison chart of our HSA-qualified plans.



Membership agreement

For detailed information about this plan, read the membership agreement.

Membership agreement for Northern California

Membership agreement for Southern California



Benefits

The table below summarizes the most frequently asked-about benefits and their copayments and coinsurance.

For more information on benefits, copayments, and coinsurance, please refer to our disclosure form.

Features

Member pays

Medical calendar-year deductible (individual/family)

$1,500/$3,000

Annual out-of-pocket maximum (individual/family)

$1,500/$3,000

Lifetime benefit maximum

None


Professional services (Plan provider office visits)

Primary and specialty care visits
(includes routine and urgent care appointments)

No charge after deductible

Well-child visits from 0 to 23 months

No charge*

Family planning visits

No charge after deductible

Scheduled prenatal care

No charge*

First postpartum visit

No charge after deductible

Eye exams

No charge after deductible

Hearing tests

No charge after deductible

Chiropractic office visits

Not covered

Physical, occupational, and speech therapy visits

No charge after deductible


Outpatient services

Outpatient surgery

No charge after deductible

Allergy injection visits

No charge after deductible

Vaccines (immunizations)

No charge*

Most X-rays and lab tests

No charge after deductible


Health education

Individual visits

No charge after deductible

Group visits

No charge after deductible


Hospitalization services

Room and board, surgery, anesthesia, X-rays, lab tests, and medications

No charge after deductible


Emergency health coverage

Emergency Department visits

No charge after deductible


Ambulance services

Emergency ambulance services

No charge after deductible


Prescription drug coverage

Covered items in accord with our drug formulary when obtained at Plan pharmacies

Generic drugs

No charge up to a 100-day supply after deductible

Brand-name drugs

No charge up to a 100-day supply after deductible


Durable medical equipment (DME)

DME used in the home in accord with our DME formulary

Not covered

Prosthetic and orthotic devices

No charge


Mental health services

Inpatient psychiatric care

No charge after deductible (up to 30 days per calendar year)

Outpatient visits—individual visits

No charge after deductible (up to 20 visits per calendar year)

Outpatient visits—group therapy visits

No charge after deductible (up to 20 visits per calendar year)

Note: Visit and day limits do not apply to severe mental illness and serious emotional disturbances of children as described in the "Benefits, deductibles, copayments, and coinsurance" section of the membership agreement.


Chemical dependency services

Inpatient detoxification

No charge after deductible

Outpatient individual therapy visits

No charge after deductible

Outpatient group therapy visits

No charge after deductible

Transitional residential recovery services

No charge after deductible (up to 60 days per calendar year, not to exceed 120 days in any five-year period)


Home health services

Home health care

No charge after deductible (up to 100 two-hour visits per calendar year)


Other

Skilled nursing facility care

No charge after deductible (100 days per benefit period)

Hospice care

No charge after deductible



* These services are not subject to the deductible.



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