Austin
(HMO) H9706-003
(PPO) H1666-004
(PPO) H4801-003
In-Network
Out-of-Network
In-Network
Out-of-Network
Plan Premium
$0
$0
$0
Doctors Office Visits
Primary Care Provider
$0 copay
$10 copay
50% coinsurance
$20 copay
$25 copay
Specialist
$35 copay
$50 copay
50% coinsurance
$50 copay
$65 copay
Maximum Out-of-Pocket
$6,700
$7,550
$11,300
$6,400
$11,300
Inpatient Hospital Copay
$275/day (days 1-5)
$372/day (days 1-5)
$372/day (days 1-5)
50% coinsurance
Retail Preferred Pharmacy
$0-$10/$10-$20/$47/$100/31%,br> Full coverage of Tier 1 in gap
$0-$10/$10-$20/$47/$100/25%
Full coverage of Tier 1 in gap
Full coverage of Tier 1 in gap
$0-$10/$10-$20/$47/$100/25%
Full coverage of Tier 1 in gap
Full coverage of Tier 1 in gap
Prescription Drug Deductible
$100 Ded (Tiers 4 and 5)
$480 (Tiers 3-5)
$480 (Tiers 3-5)
Extra Health & Wellness Benefits
Optional Supplemental Benefits Premium
N/A
N/A
$31.60
Dental
Preventive
$0 copay 2 exams, 2 cleanings, 1 X-ray
Not Covered
$0 copay 2 exams, 2 cleanings, 1 x-ray
Comprehensive
$500 Allowance/Year
Not Covered
Optional Supplemental Available
Vision
Eye Exam
$0 copay (routine) 1 per year
$0 copay
$40 allowance
$0 copay (routine) 1 per year
$40 allowance
Eye Wear
$0 copay Medicare Covered $100 allowance per year
Not Covered
Not Covered
$0 copay Medicare Covered $125 allowance per year
$0 copay Medicare Covered $125 allowance per year
Hearing Aids
$699 Advanced $999 Premium
Not Covered
$1,000 hearing aid allowance/every 3 years
Over-The-Counter (OTC) Purchase Allowance
$50 quarterly
Not Covered
Not Covered
Silver Sneakers Fitness Program
✓
✓
✓
24/7 Nurse Line
✓
✓
✓
Transportation
12 one-way trips
Not Covered
Not Covered
Rewards
✓
✓
✓
Telehealth
MD Live $0 copay Urgent Care Only
MD Live $0 copay Urgent Care Only
MD Live $0 copay Urgent Care Only