Summit Health Premier + Rx (HMO-POS)
Plan highlights
- Includes a prescription drug benefit with $0 copay on preferred generics and Part D vaccines
- No referral required for Specialty care
- $0 medical deductible
- $0 copay for PCP visits
- $0 copay preventive dental services
- $0 copay routine hearing and vision exams
- $0 copay fitness benefit
- Plus coverage for routine chiropractic, acupuncture, and naturopathic services
- Coverage for Over-the-Counter items
Premium
$170/mo.
Eastern Oregon
Plan overview
Copays & coinsurance
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| Calendar year costs | In-network | Out-of-network |
|---|---|---|
| Medical deductible | This plan does not have a deductible. | |
| Out-of-pocket maximum | Your yearly limit in this plan: $4,850 for services from any In-network provider | $7,990 for services you receive from any Medicare provider |
| Inpatient care | In-network | Out-of-network |
| Inpatient hospital care | You pay a $325 copay per day for days 1 through 5. You pay nothing per day for days 6 and beyond. | You pay a 30% of the cost. |
| Skilled nursing facility | You pay nothing per day for days 1 through 20. You pay a $170 copay per day for days 21 through 100. | You pay 30% of the cost per stay. |
| Outpatient care | In-network | Out-of-network |
| PCP office visit | You pay a $0 copay per visit. | You pay 30% of the cost per visit. |
| Specialist office visit | You pay a $35 copay per visit. | You pay 30% of the cost per visit. |
| Outpatient hospital services | You pay a $325 copay. | You pay 30% of the cost. |
| Ambulance | You pay a $275 copay. | You pay a $275 copay. |
| Emergency care | You pay a $110 copay per visit. | You pay a $110 copay per visit. |
| Urgently needed services | You pay a $35 copay per visit. | You pay a $35 copay per visit. |
| Durable medical equipment (DME) | You pay 20% of the cost. | You pay 30% of the cost. |
| Outpatient lab test and services | You pay a $5 copay. | You pay 30% of the cost. |
| Diagnostic imaging (X-ray/CT/MRI) | You pay 20% of the cost. | You pay 30% of the cost. |
| Outpatient rehab: OT/PT/ST | You pay a $35 copay. | You pay 30% of the cost. |
| Preventive care | In-network | Out-of-network |
| Medicare-covered preventive services | You pay nothing. | You pay 30% of the cost. |
| Other services | In-network | Out-of-network |
| Routine vision exam | You pay nothing. | You pay 50% of the cost. |
| Routine vision hardware | You pay nothing. | You pay 50% of the cost for lens with a $50 allowance towards frames. |
| Preventive and comprehensive dental | You pay nothing for preventive services or 20% for comprehensive services up to a combined $1,500 annual maximum allowance. | You pay 50% for all services up to a combined $1,500 annual maximum allowance. |
| Hearing aids | You pay $599 or $899 for each hearing aid. | Not covered |
| Prescription medications | In-network | Out-of-network |
| Pharmacy deductible | $100 (Waived on Tiers 1, 2, & 7) | Not applicable |
| Tier 1 (preferred generic) | You pay a $0 at a preferred or mail order pharmacy. | Not applicable |
| Tier 2 (generic) | You pay a $7 copay at a preferred or mail order pharmacy. | Not applicable |
| Tier 3 (preferred brand) | You pay a $40 copay at a preferred or mail order pharmacy. | Not applicable |
| Tier 4 (non-preferred brand) | You pay a $93 copay at a preferred or mail order pharmacy. | Not applicable |
| Tier 5 (preferred specialty) | You pay 26% of the cost. | Not applicable |
| Tier 6 (specialty) | You pay 31% of the cost. | Not applicable |
| Tier 7 (vaccine) | Your pay a $0 copay. | Not applicable |
| Show medication costs | ||
Premium
$170/mo.
Eastern Oregon
Last updated Oct. 1, 2023
H2765_4006