Updated as of 11/1/ Individual & Family. Health Insurance
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1 Updated as of 11/1/ Individual & Family Health Insurance
2 2018 Plan Options for Individuals and Families In-network benefits are described on the chart. For out-of-network benefits or more details, please refer to the Summary of Benefits and Coverage found at HealthPlans.com, under the Shop Plans for Individuals section. Plan Details: *These plans are considered highdeductible health plans (HDHP) that can be paired with a Health Savings Account. **Examples include gynecological exam, screening mammography, well-child care and newborn care. Limitations do apply. For a detailed listing, visit HealthPlans.com. On and Off Exchange Plans Deductible Individual $1,500 $2,750 Family $3,000 $5,500 30% 30% Out-of-Pocket Maximum Individual $3,500 $7,100 Family $7,000 $14,200 Medical Benefits Preventive Care Services Primary Care Physician Visit Co-pay $25 Specialist Visit Co-pay $50 Urgent Care Services Co-pay $25 Lab and X-Ray (Diagnostic Test) No cost to you. This includes preventive im Hospital Services Emergency Services Maternity Services Pediatric Vision Services Pediatric Dental Services Mental Health and Substance Use Disorder Outpatient Services Co-pay $25 Inpatient Services Pharmacy Benefits Pharmacy Deductible - Individual - Family Tier 1: Preventive Medications $0 Tier 2: Preferred Generics $0 Tier 3: Non-Preferred Generics $50 Tier 4: Preferred Brands $50 Tier 5: Non-Preferred Brands $150 Tier 6: Specialty Medications (brand and generic) $0 $0 $0 $0 / Gold Silver Quote: $ $
3 Application ID # * * 7350 $2,800 $3,500 $4,000 $5,500 $6,550 $7,350 $5,600 $7,000 $8,000 $11,000 $13,100 $14,700 40% 40% 0% 40% 0% 0% $6,800 $7,200 $4,000 $7,350 $6,550 $7,350 $13,600 $14,400 $8,000 $14,700 $13,100 $14,700 munizations, screenings, exams** Co-pay $45 Co-pay $50 Co-pay $75 Co-pay $80 Please note: Cost Share Reduction plans may not qualify. the Co-pay $40/visit for first three visits then subject to Please note: Cost Share Reduction plans may not qualify. the Co-pay $0 Maximum 3 visits 0% Co-pay $45 Co-pay $50 Co-pay $40 Co-pay $0 Maximum 3 visits 0% Included Co-pay $45 Co-pay $50 Co-pay $40/visit for first three visits then subject to Co-pay $0 Maximum 3 visits $0 $0 $0 $50 $0 $0 $0 $0 $0 $100 $0 $0 $0 $0 $0 $10 $10 $30 $50 $75 $30 $50 $100 the medical $30 $75 $150 $150 40% coinsurance/ $0 40% coinsurance/ the medical To qualify for this plan you must be under the age of 30 before Jan. 1 or qualify for a federal hardship exemption. Silver Silver Silver Bronze Bronze Catastrophic $ $ $ $ $ $
4 Off Exchange Plans * Deductible Individual $2,500 $3,000 $5,000 $6,000 Family $5,000 $6,000 $10,000 $12,000 30% 40% 40% 0% Out-of-Pocket Maximum Individual $6,000 $6,500 $7,350 $6,000 Family $12,000 $13,000 $14,700 $12,000 Medical Benefits Preventive Care Services No cost to you. This includes preventive immunizations, screenings, exams** Primary Care Physician Visit Co-pay $30 Co-pay $40 Specialist Visit Co-pay $75 Co-pay $100 Co-pay $40/visit for first three visits then subject to Urgent Care Services Co-pay $30 Co-pay $40 Co-pay $40 Lab and X-Ray (Diagnostic Test) Hospital Services Emergency Services Maternity Services Pediatric Vision Services Pediatric Dental Services Mental Health and Substance Use Disorder Outpatient Services Co-pay $30 Co-pay $40 Inpatient Services Pharmacy Benefits Pharmacy Deductible - Individual - Family Co-pay $40/visit for first three visits then subject to the $50 $50 $50 $0 $100 $100 $100 $0 Tier 1: Preventive Medications $0 $0 $0 Tier 2: Preferred Generics $10 $10 $10 Tier 3: Non-Preferred Generics $30 $30 $30 Tier 4: Preferred Brands $50 $50 $75 Tier 5: Non-Preferred Brands $100 $150 $150 Tier 6: Specialty Medications (brand and generic) / / Application ID # / the medical Silver Silver Bronze Bronze Quote: $ $ $ $
5 Off Exchange Stanley County * Deductible Individual $2,500 $6,250 Family $5,000 $12,500 30% 0% Out-of-Pocket Maximum Individual $6,000 $6,250 Family $12,000 $12,500 Medical Benefits Preventive Care Services No cost to you. This includes preventive immunizations, screenings, exams** Primary Care Physician Visit Co-pay $30 Specialist Visit Co-pay $75 Urgent Care Services Co-pay $30 Lab and X-Ray (Diagnostic Test) Hospital Services Emergency Services Maternity Services Deductible and coinsurance apply for all Deductible and coinsurance apply for all Deductible and coinsurance apply for all Pediatric Vision Services Pediatric Dental Services Mental Health and Substance Use Disorder Outpatient Services Co-pay $30 Inpatient Services Pharmacy Benefits Pharmacy Deductible - Individual - Family Deductible and coinsurance apply for all Tier 1: Preventive Medications $0 Tier 2: Preferred Generics $10 Tier 3: Non-Preferred Generics $30 Tier 4: Preferred Brands $50 Tier 5: Non-Preferred Brands $100 Tier 6: Specialty Medications (brand and generic) after meeting the $50 $0 $100 $0 / Silver Application ID # after meeting the medical Bronze Quote: $ $
6 Discrimination is Against the Law Health Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Health Plans: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as: qualified interpreters and information written in other languages. If you need these services, contact the Health Plans Service Center at , (TTY 711), 8 a.m. to 5 p.m. CST, Monday through Friday. If you believe that Health Plans has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: You can file a grievance in person or by mail, fax, or . You may also contact the Complaint and Appeals Coordinator if you need assistance with filing a complaint. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or call or (TDD). Or mail: US Department of Health and Human Services, 200 Independence Avenue SW Room 509F, HHH Building, Washington, D.C Complaint forms are available at Complaint and Appeals Coordinator Health Plans 3816 S. Elmwood, Suite 100, Sioux Falls, SD Fax ComplaintAppeals@HealthPlans.com Getting Help in other Languages Language assistance services are available free of charge. Our Service Center is available 8 a.m. to 5 p.m. CST, Monday Friday, toll-free at (TTY: ). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). US CEEV: Yo g tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: ). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (TTY: ). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: ). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: (TTY: ). ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم: ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລ ການຊ ວຍເຫ ອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມ ພ ອມໃຫ ທ ານ. ໂທຣ (TTY: ) (TTY: ). ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (TTY: ). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ (መስማት ለተሳናቸው: ) OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: ) ប រយ ត ន បរ ស នជ អ នកន យ យ ភ ស ខ ម រ, បសវ ជ ន យខ នកភ ស ប យម នគ ត ឈ ន ល គ អ ចម នស រ រ រ បរ អ នក ច រ ទ រស ព ទ (TTY: ) Form PS (Rev. 2/17)
7 Questions? Visit HealthPlans.com or call My to get a quote. Additional resources are available at HealthPlans.com Consumer Guide Provider Directory Drug Formulary Find an Agent Health Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: ). Network restrictions apply with Select Standard plans available. Neither Health Plans nor its agents are connected with Medicare or state or federal government. This is a solicitation and you will talk to an Health Plans sales associate but are under no obligation to purchase. 17-AVHP-8005-REV1017
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