Private Health Insurance Plans
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| Benefit |
ULTRA 1000 Lower Deductible |
ULTRA 3000 Most Popular Best Value |
ULTRA 6000 Lower Premium |
|---|---|---|---|
| In-Network Benefits | |||
| Deductible (Ind / Family) | $1,000 / $2,000 | $3,000 / $6,000 | $6,000 / $12,000 |
| Max Out-of-Pocket (Ind / Family) | $5,000 / $10,000 | $9,450 / $18,900 | $9,450 / $18,900 |
| Coinsurance | 80% | 70% | 70% |
| Office Visits | |||
| Primary Care | $20 copay | $30 copay | $30 copay |
| Specialist | $40 copay | $60 copay | $60 copay |
| Urgent Care | $40 copay | $60 copay | $60 copay |
| Preventive Care | Covered 100% | Covered 100% | Covered 100% |
| Diagnostics & Imaging | |||
| Diagnostic Tests / X-Rays | No charge after deductible In-network freestanding X-rays 100% covered |
$30 copay/visit | $30 copay/visit |
| CT, PET, MRI | 20% after deductible Precertification required |
30% after deductible Precertification required |
30% after deductible Precertification required |
| Hospital & Emergency | |||
| Hospitalization | 20% after deductible Precert required; 50% reduction if not obtained (max $2,500) |
30% after deductible Precert required; 50% reduction if not obtained (max $10,000) |
30% after deductible Precert required; 50% reduction if not obtained (max $10,000) |
| Emergency Room | 20% after deductible | 30% after deductible | 30% after deductible |
| Emergency Medical Transport | 20% after deductible | 30% after deductible | 30% after deductible |
| Maternity | 20% after deductible | 30% after deductible | 30% after deductible |
| Mental Health | |||
| Mental Health Outpatient | $20 copay/visit | $30 copay/visit | $30 copay/visit |
| Mental Health Inpatient | 20% after deductible Precert required; max $500 reduction |
30% after deductible Precert required; max $500 reduction |
30% after deductible Precert required; max $500 reduction |
| Rehab, Home & Skilled Care | |||
| Rehab / Habilitative Services | $20 copay/visit 20 visits combined OT/PT/Speech; 20 cardiac rehab; 15 chiro per year |
$60 copay/visit Same visit limits apply |
$60 copay/visit Same visit limits apply |
| Home Health Care | 20% after deductible | 30% after deductible | 30% after deductible |
| Skilled Nursing | 20% after deductible Up to 90 days/year |
30% after deductible Up to 60 days/year |
30% after deductible Up to 60 days/year |
| Durable Medical Equipment | 20% after deductible | 30% after deductible | 30% after deductible |
| Hospice Services | 20% after deductible | 30% after deductible | 30% after deductible |
| Prescription Drugs (In-Network) | |||
| Generic | $15 | $15 | $15 |
| Brand Name | $45 | $65 | $65 |
| Non-Preferred Brand | $85 | $100 | $100 |
| Specialty | Through MyRX PAP application required |
Not Covered | Not Covered |
| 31–90 Day Supply | Generic $45 | Brand $90 | Non-Preferred Brand $150 — Retail & Mail Order | ||
| Out-of-Network Benefits | |||
| Deductible (Ind / Family) | $2,000 / $4,000 | $6,000 / $12,000 | $12,000 / $24,000 |
| Max Out-of-Pocket (Ind / Family) | $10,000 / $20,000 | $18,950 / $37,900 | $18,900 / $37,900 |
| Coinsurance | 60% | 40% | 40% |
| Reimbursement Basis | Plans Allowable Fee | ||
| More info | View plan details → | View plan details → | View plan details → |