Plan Details
Costs and Other Important Information
Plan Year:
2018
Optional Supplemental Benefits
No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$8,000 In and Out-of-network
$3,500 In-network
Other health plan deductibles?
No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$33.60
Monthly Health Plan Premium
$5.40
Benefits
Service
Cost
Inpatient hospital coverage
In-Network:
$295 for days 1 through 4
$0 for days 5 through 90
Out-of-Network:
30% per stay
$295 for days 1 through 4
$0 for days 5 through 90
Out-of-Network:
30% per stay
Outpatient hospital coverage
In-Network:
$20-200 per visit
Out-of-Network:
30% per visit
$20-200 per visit
Out-of-Network:
30% per visit
Doctor visits
Primary:
In-Network:
$5 per visit
Out-of-Network:
30% per visit
Specialist:
In-Network:
$20 per visit
Out-of-Network:
30% per visit
In-Network:
$5 per visit
Out-of-Network:
30% per visit
Specialist:
In-Network:
$20 per visit
Out-of-Network:
30% per visit
Preventive care
In-Network:
$0 copay
Out-of-Network:
30%
$0 copay
Out-of-Network:
30%
Emergency care/Urgent care
Emergency:
$80 per visit (always covered)
Urgent care:
$20 per visit (always covered)
$80 per visit (always covered)
Urgent care:
$20 per visit (always covered)
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures:
In-Network:
$0 copay
Out-of-Network:
30%
Lab services:
In-Network:
$0 copay
Out-of-Network:
30%
Diagnostic radiology services (e.g., MRI):
In-Network:
$200
Out-of-Network:
30%
Outpatient x-rays:
In-Network:
$0 copay
Out-of-Network:
30%
In-Network:
$0 copay
Out-of-Network:
30%
Lab services:
In-Network:
$0 copay
Out-of-Network:
30%
Diagnostic radiology services (e.g., MRI):
In-Network:
$200
Out-of-Network:
30%
Outpatient x-rays:
In-Network:
$0 copay
Out-of-Network:
30%
Mental health services
In-Network:
$295 for days 1 through 4
$0 for days 5 through 90
Out-of-Network:
30% per stay
Outpatient group therapy visit with a psychiatrist:
In-Network:
$20
Out-of-Network:
30%
Outpatient individual therapy visit with a psychiatrist:
In-Network:
$20
Out-of-Network:
30%
Outpatient group therapy visit:
In-Network:
$20
Out-of-Network:
30%
Outpatient individual therapy visit:
In-Network:
$20
Out-of-Network:
30%
$295 for days 1 through 4
$0 for days 5 through 90
Out-of-Network:
30% per stay
Outpatient group therapy visit with a psychiatrist:
In-Network:
$20
Out-of-Network:
30%
Outpatient individual therapy visit with a psychiatrist:
In-Network:
$20
Out-of-Network:
30%
Outpatient group therapy visit:
In-Network:
$20
Out-of-Network:
30%
Outpatient individual therapy visit:
In-Network:
$20
Out-of-Network:
30%
Skilled Nursing Facility
In-Network:
$0 for days 1 through 20
$155 for days 21 through 100
Out-of-Network:
30% per stay
$0 for days 1 through 20
$155 for days 21 through 100
Out-of-Network:
30% per stay
Rehabilitation services
Occupational therapy visit:
In-Network:
$20
Out-of-Network:
30%
Physical therapy and speech and language therapy visit:
In-Network:
$20
Out-of-Network:
30%
In-Network:
$20
Out-of-Network:
30%
Physical therapy and speech and language therapy visit:
In-Network:
$20
Out-of-Network:
30%
Ambulance
In-Network:
$215
Out-of-Network:
$215
$215
Out-of-Network:
$215
Transportation
Not covered
Foot care (podiatry services)
Foot exams and treatment:
In-Network:
$20
Out-of-Network:
30%
Routine foot care:
Not covered
In-Network:
$20
Out-of-Network:
30%
Routine foot care:
Not covered
Medical equipment/supplies
Durable medical equipment (e.g., wheelchairs, oxygen):
In-Network:
20% per item
Out-of-Network:
30% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network:
20% per item
Out-of-Network:
30% per item
Diabetes supplies:
In-Network:
20% per item
Out-of-Network:
30% per item
In-Network:
20% per item
Out-of-Network:
30% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network:
20% per item
Out-of-Network:
30% per item
Diabetes supplies:
In-Network:
20% per item
Out-of-Network:
30% per item
Wellness programs (e.g., fitness, nursing hotline)
Covered
Medicare Part B drugs
Chemotherapy:
In-Network:
20%
Out-of-Network:
30%
Other Part B drugs:
In-Network:
20%
Out-of-Network:
30%
In-Network:
20%
Out-of-Network:
30%
Other Part B drugs:
In-Network:
20%
Out-of-Network:
30%
Coverage Area for HealthPartners UnityPoint Health Symmetry (PPO)
| State | Iowa |
|---|---|
| County | Polk |
Cost Sharing Information
All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit
| 30 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
|---|---|---|---|
| Tier 1: Preferred Generic | Not offereds | $2 copay | $2 copay |
| Tier 2: Non-Preferred Generic | Not offered | $9 copay | $9 copay |
| Tier 3: Preferred Brand Name | Not offered | $47 copay | $47 copay |
| Tier 4: Non-Preferred Brand Name | Not offered | $100 copay | $100 copay |
| Tier 5: Specialty Tier | Not offered | 31% coinsurance | 31% coinsurance |
| 90 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
|---|---|---|---|
| Tier 1: Preferred Generic | Not offered | $6 copay | $4 copay |
| Tier 2: Non-Preferred Generic | Not offered | $27 copay | $18 copay |
| Tier 3: Preferred Brand Name | Not offered | $141 copay | $117.5 copay |
| Tier 4: Non-Preferred Brand Name | Not offered | $300 copay | $250 copay |
| Tier 5: Specialty Tier |
CMS Ratings
Staying healthy - screenings, tests and vaccines
Breast cancer screening
Not Rated
Colorectal cancer screening
Not Rated
Annual flu vaccine
Not Rated
Improving or maintaining physical health
Not Rated
Improving or maintaining mental health
Not Rated
Monitoring physical ability
Not Rated
Adult BMI assessment
Not Rated
Managing Chronic Conditions
Special needs plan care management
Not Rated
Care for older adults – medication review
Not Rated
Care for older adults – functional status assessment
Not Rated
Care for older adults – Pain screening
Not Rated
Osteoporosis management in women who had a fracture
Not Rated
Diabetes care – eye exam
Not Rated
Diabetes care – kidney disease monitoring
Not Rated
Diabetes care – blood sugar controlled
Not Rated
Controlling blood pressure
Not Rated
Rheumatoid arthritis management
Not Rated
Reducing the risk of falling
Not Rated
Plan all-cause readmissions
Not Rated
Member Experience with Health Plan
Getting needed care
Not Rated
Getting appointments and care quickly
Not Rated
Customer service
Not Rated
Overall rating of health care quality
Not Rated
Overall rating of plan
Not Rated
Care Coordination
Not Rated
Member Complaints, and Changes in Health Plan's Performance
Complaints about the health plan
Not Rated
Members choosing to leave the health plan
Not Rated
Beneficiary access and performance problems
Not Rated
Health plan quality improvement
Not Rated
Health Plan Customer Service
Plan makes timely decision about appeals
Not Rated
Reviewing appeals decisions
Not Rated
Call center – foreign language interpreter and TTY/TDD availability - Medical
Not Rated
Drug Plan Customer Service
Call center – foreign language interpreter and TTY/TDD availability - Drugs
Not Rated
Appeals auto-forward
Appeals upheld
Member Complaints, and Changes in Drug Plan's Performance
Complaints about the drug plan
Not Rated
Members choosing to leave the drug plan
Not Rated
Beneficiary access and performance problems
Not Rated
Drug plan quality improvement
Not Rated
Member Experience with Drug Plan
Rating of drug plan
Not Rated
Getting needed prescription drugs
Not Rated
Drug Pricing and Patient Safety
MPF Price Accuracy
Not Rated
High risk medication
Not Rated
Part D medication adherence for diabetes
Not Rated
Part D medication adherence for hypertension
Not Rated
Part D medication adherence for cholesterol
Not Rated
Medication Therapy Management program completion rate
Not Rated
Physician Finder
Physicians that accept HealthPartners UnityPoint Health Symmetry (PPO) for Iowa
/
No results found. Try changing the search distance or zip code.
