| PPO (North Texas) | |
|---|---|
| Monthly Premium | $0 |
| Deductible | $0 |
| Out-of-Pocket Maximum | $6,400 |
| Annual Physical Exam | $0 copay |
| Primary Care Physician (PCP) Office Visit | $0 copay |
| Specialty Care Physician (SCP) Office Visit | $35 copay |
| Telehealth Visit (PCP, SCP, Psychiatry Services) | $0 copay |
| Diagnostic Tests, X-rays, Lab Services (separate office visit copay may apply) | $0 copay |
| Advanced Diagnostic Imaging Services (MRI, MRA, SPECT, CTA) | $0-$300 copay |
| Physical/Occupational/Speech Therapy (per visit) | $35 copay |
| Inpatient Hospital | Day 1-6: $320/day per stay Day 7-90: $0/day per stay |
| Inpatient Mental Health | Day 1-5: $318/day per stay Day 6-90: $0/day per stay |
| Skilled Nursing Facility (SNF) | Day 1-20: $0/day Day 21-100: $218/day |
| Outpatient Surgery (facility) | $350 copay |
| Ambulatory Surgical Center (facility) | $275 copay |
| Ambulance (ground and air) | $325 copay |
| Emergency Care (within the U.S.; copay waived if admitted within 24 hours) | $130 copay |
| Urgent Care (within the U.S.; copay waived if admitted within 24 hours) | $50 copay |
| Durable Medical Equipment (DME) | 20% coinsurance |
| Podiatry | $45 copay |
| Chemotherapy Drugs | 0%-20% coinsurance |
| Other Part B Drugs | 0%-20% coinsurance |
| Prescription Drug Benefits (applies to plans with Part D only) | |
| Deductible | $300 (Applies to Tiers 3-5) |
| Tier 1 – Preferred Generic Drugs (30-day supply) | $0/$5 copay |
| Tier 2 – Generic Drugs (30-day supply) | $7/$14 copay |
| Tier 3 – Preferred Brand Drugs (30-day supply) | $47/$47 copay |
| Tier 4 – Non-Preferred Drugs (30-day supply) | 35% coinsurance |
| Tier 5 – Specialty Drugs (30-day supply) | 29% coinsurance |
| Mail Order Copays (90-day supply) | Tiers 1 – 2 are $0 copay; Tier 3 is two copays; Tier 4 is 35% coinsurance |
| Total Out-of-Pocket You Pay Before Catastrophic Coverage | $2,100 |
| Catastrophic Coverage Amounts – You Pay | $0 copay |
| Dental Benefits | |
| Monthly Premium | Included |
| Yearly Benefit Maximum | $3,500 |
| Deductible | $0 |
| Oral Exams (One every 6 months) | $0 |
| Cleanings (One every 6 months) | $0 |
| Dental X-rays | $0 |
| Extractions | 50% coinsurance |
| Fillings (One filling per surface, per tooth every 24 months) | 0%- 50% coinsurance |
| Dentures (every 5 years) | $0 copay |
| Supplemental Benefits | |
| Routine Eye Exam (one per year; must use a network provider) | $0 copay |
| Eyewear (annually; must use network provider) | $150 allowance |
| Routine Hearing Exam (one per year) | $0 copay |
| Hearing Aids (every 3 years) | $1,100 allowance |
| Fitness Membership (Home fitness programs, activity tracker, and/or gym/fitness club membership at participating locations) | $0 |
Want help comparing your plans and benefits—and finding the right choice for your needs? Are you ready to enroll?
Call 833.975.0841833.975.0841 (TTY: 711) to speak with a licensed insurance agent.
October 1 – March 31: 7 days a week, 8:00 AM – 8:00 PM
April 1 – September 30: Monday – Friday, 8:00 AM – 5:00 PM
Closed on major holidays.
Para hablar con un representante en español, llame a 833.412.3320833.412.3320.
Already a member? Visit our Member Resources.
