Plan Details
Costs and Other Important Information
Plan Year:
2018
Optional Supplemental Benefits
Yes
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$6,700 In-network
Other health plan deductibles?
No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$0.00
Monthly Health Plan Premium
$0.00
Benefits
Service
Cost
Inpatient hospital coverage
$199 for days 1 through 10
$0 for days 11 through 90
$0 for days 11 through 90
Outpatient hospital coverage
$160 per visit
Doctor visits
Primary:
$0 copay
Specialist:
$40 per visit
$0 copay
Specialist:
$40 per visit
Preventive care
$0 copay
Emergency care/Urgent care
Emergency:
$80 per visit (always covered)
Urgent care:
$35 per visit (always covered)
$80 per visit (always covered)
Urgent care:
$35 per visit (always covered)
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures:
$0 copay
Lab services:
$0 copay
Diagnostic radiology services (e.g., MRI):
$175
Outpatient x-rays:
$40
$0 copay
Lab services:
$0 copay
Diagnostic radiology services (e.g., MRI):
$175
Outpatient x-rays:
$40
Mental health services
$199 for days 1 through 8
$0 for days 9 through 90
Outpatient group therapy visit with a psychiatrist:
$40
Outpatient individual therapy visit with a psychiatrist:
$40
Outpatient group therapy visit:
$40
Outpatient individual therapy visit:
$40
$0 for days 9 through 90
Outpatient group therapy visit with a psychiatrist:
$40
Outpatient individual therapy visit with a psychiatrist:
$40
Outpatient group therapy visit:
$40
Outpatient individual therapy visit:
$40
Skilled Nursing Facility
$0 for days 1 through 20
$160 for days 21 through 100
$160 for days 21 through 100
Rehabilitation services
Occupational therapy visit:
$15
Physical therapy and speech and language therapy visit:
$15
$15
Physical therapy and speech and language therapy visit:
$15
Ambulance
$250
Transportation
Not covered
Foot care (podiatry services)
Foot exams and treatment:
$40
Routine foot care:
Not covered
$40
Routine foot care:
Not covered
Medical equipment/supplies
Durable medical equipment (e.g., wheelchairs, oxygen):
20% per item
Prosthetics (e.g., braces, artificial limbs):
20% per item
Diabetes supplies:
20% per item
20% per item
Prosthetics (e.g., braces, artificial limbs):
20% per item
Diabetes supplies:
20% per item
Wellness programs (e.g., fitness, nursing hotline)
Covered
Medicare Part B drugs
Chemotherapy:
20%
Other Part B drugs:
20%
20%
Other Part B drugs:
20%
Coverage Area for Allwell Medicare (HMO)
| State | Louisiana |
|---|---|
| County | East Baton Rouge Parish |
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 | $0 copay | $5 copay | Not offered |
| Tier 2: Non-Preferred Generic | $10 copay | $15 copay | Not offered |
| Tier 3: Preferred Brand Name | $37 copay | $47 copay | Not offered |
| Tier 4: Non-Preferred Brand Name | $90 copay | $100 copay | Not offered |
| Tier 5: Specialty Tier | 27% coinsurance | 27% coinsurance | Not offered |
| 90 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
|---|---|---|---|
| Tier 1: Preferred Generic | $0 copay | $15 copay | Not offered |
| Tier 2: Non-Preferred Generic | $30 copay | $45 copay | Not offered |
| Tier 3: Preferred Brand Name | $111 copay | $141 copay | Not offered |
| Tier 4: Non-Preferred Brand Name | $270 copay | $300 copay | Not offered |
| Tier 5: Specialty Tier |
Physician Finder
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