| Service |
Cost Alliance |
Key Advantage |
| PCP Co-payment |
$20 |
$20 |
| Specialist Copayment |
$35 |
$30 |
| Hospital Inpatient Copayment |
$100 Per day up to $500 |
$300 Per Confinement |
| Hospital Outpatient Copayment |
$75 Per visit (waived if admitted) |
$100 Per visit (waived if admitted) |
| Prescription Copayment |
$20 up to 34 day supply
$40 for 35-90 day supply |
$17 for up to 34 day supply
$34 for up 35 to 90 day supply |
| Mail Order Prescriptions |
$28 for up to a 90-day supply |
$25 for up to a 90-day supply |
| Dental |
No standard Dental
Additional Dental Available:
100% for 2 check ups & cleanings per year;
80/20% for Primary Services;
50/50% for Complex Restorative;
Orthodontics - $1,200 lifetime max;
50/50% coverage after the 1 year waiting period; |
Dental included in Key Advantage Standard Package:
100% for 2 check ups & cleanings per year;
80/20% for Primary Services;
Expanded Package available
|
| Expanded Package |
Not available |
Additional Dental:
50/50% for Complex Restorative;
Orthodontics - $1,200 lifetime max;
50/50% coverage after a 1 year waiting period;
Vision
Plan pays once every 24 months:
$75 for eyeglass frames
$50 for single vision lenses
$75 for bifocal lenses
$100 for trifocal lenses
$100 for contact lenses
Preventive Care
Additional Preventative Testing
Additional Immunizations
|
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