WHA Benefit Comparison Small Group 2015

TRADITIONAL PLANS

GATEWAY 20 PLATINUM

GATEWAY 30 PLATINUM

GATEWAY 70 PLATINUM

CAPITAL/ SHOP PLATINUM 90

CAPITAL/ SHOP GOLD 80

PLAN BENEFIT COMPARISON Small Group — Effective 1.1.15

None

None

None

None

None

INDIVIDUAL

Deductible — Medical 1

None

None

None

None

None

FAMILY

None

None

None

None

None

INDIVIDUAL

Deductible — Prescription 1

None

None

None

None

None

FAMILY

$4,000

$4,000

$4,000

$4,000

$6,250

INDIVIDUAL

Annual out-of-pocket maximum 2

$8,000

$8,000

$8,000

$8,000

$12,500

FAMILY

PREVENTIVE CARE SERVICES 3, 4 Annual physical examinations

Immunizations, adult and pediatric Women’s preventive services Maternity care, routine prenatal and lab tests and first post-natal visit Well baby care Breast, cervical, prostate and colorectal cancer screenings PROFESSIONAL/OUTPATIENT SERVICES 3

Covered in Full

Office visits, Primary Care Physician $20 per visit

$30 per visit $30 per visit

$20 per visit $20 per visit

$20 per visit $40 per visit

$30 per visit $50 per visit

Office visits, Specialist

$20 per visit

Adult vision examination

Covered in Full

Covered in Full

Covered in Full

Covered in Full

Covered in Full

Pediatric vision, including examination and eyewear, up to age 19 5 Outpatient surgery (performed in office setting)

$20 per visit $100 per visit

$30 per visit $100 per visit Covered in Full Covered in Full

$20 per visit $100 per visit Covered in Full Covered in Full

$20/40 per visit 9 $250 per visit $20 per visit $40 per visit $150 per visit $250 per day, days 1-5 $150 per day, days 1-5 $20 per visit $250 per day, days 1-5 $250 per day, days 1-5

$30/50 per visit 9 $600 per visit $30 per visit $50 per visit $250 per visit $600 per day, days 1-5 $300 per day, days 1-5 $30 per visit $600 per day, days 1-5 $600 per day, days 1-5

Outpatient surgery (facility)

Laboratory tests Covered in Full

X-ray and diagnostic imaging Covered in Full

Imaging (CT/PET scans and MRIs) HOSPITALIZATION SERVICES

$100 per visit

$100 per visit

$100 per visit

$300 per day, days 1-3 $300 per day, days 1-3 $30 per visit $300 per day, days 1-3 $300 per day, days 1-3

Hospital inpatient services Covered in Full

30% 10

Skilled nursing care, up to 100 days Covered in Full

30% 10

BEHAVIORAL HEALTH SERVICES Outpatient mental health and substance abuse $20 per visit

$20 per visit

Inpatient mental health disorders Covered in Full

30% 10

Inpatient substance abuse, including detoxification Covered in Full

30% 10

OTHER SERVICES Emergency room (waived if admitted)

$100 per visit $50 per visit

$100 per visit $50 per visit Covered in Full

$100 per visit $50 per visit Covered in Full

$150 per visit $40 per visit $150 per trip

$250 per visit $60 per visit $250 per trip

Urgent care center

Ambulance services Covered in Full

Durable medical equipment 6

20% 10

20% 10

20% 10

10% 10

20% 10

Home health services, up to 100 visits Covered in Full

Covered in Full

Covered in Full

$20 per visit $15 per visit $15 per visit

$30 per visit $15 per visit $15 per visit

Acupuncture 7

$15 per visit $15 per visit

$15 per visit $15 per visit

$15 per visit $15 per visit

Chiropractic, up to 20 visits 7

Provided through Access Dental Plan, including: Diagnostic and preventive dental care at no cost, basic dental care services, major dental care services, orthodontics when determined medically necessary; see additional benefit information

Pediatric dental, up to age 19 8

PRESCRIPTION SERVICES Tier 1 — Preferred generic medication Tier 2 — Preferred brand name medication

$5

$5

$5

$5

$15 $50 $70

$25 $45

$25 $45

$25 $45

$15 $25

Tier 3 — Non-Preferred medication

20%, up to $100/month 10

20%, up to $100/month 10

Tier 4 — Specialty medication 20%, up to $100/month 10

10% 10

20% 10

Made with