Important Questions

Answers

Why this Matters:

What is the overall deductible?

Integrated In-Network Tier 1/Tier 2: $3,400 individual / $6,800 family 
Out-of-Network: $10,000 individual / $20,000 family
Doesn’t apply to preventive care.

You must pay all the costs up to the deductibleamount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductiblestarts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. In-Network Tier 1/Tier 2 deductible is one integrated deductible. It is separate for the Out-of-Network Deductible.

Are there other deductibles for specific services?

No.  

You don’t have to meet deductibles for specific services but see the chart starting on page 2 for other costs for services this plan covers.

Is there an Out–of–Pocket limit on my expenses?

Yes.  For In-Network Tier 1/Tier 2 providers: $6,850 individual / $13,700 family
For Out-of-Network providers: Unlimited individual
/ Unlimited family

The Out-of-Pocket limitis the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. In-Network Tier 1/Tier 2 Annual Out-of-Pocket limits are one integrated Out-of-Pocket limit and is separate from Out-of-Network Annual Out-of-Pocket limit.

What is not included in the Out–of–Pocket limit?

Premiums, balance-billed charges, and health care this plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the Out-of-Pocket limit. 

Is there an overall annual limit on what the plan pays?

No. 

The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.

Does this plan use a network of providers?

Yes. See www.landoflincolnhealth.org/find-a-doctoror call 1-844-674-3834 for a list of participating providers.

If you use an In-Network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your In-Network doctor or hospital may use an Out-of-Network provider for some services. Plans use the term In-Network or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. 

Do I need a referral to see a specialist?

No. 

You can see the specialistyou choose without permission from this plan.

Are there services this plan doesn’t cover?

Yes.

Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services.

Services You May Need

Your Cost If You Use an In-Network Tier 1 Provider

Your Cost If You Use an In-Network Tier 2 Provider

Your Cost If You Use an Out-of-Network Provider

Limitations & Exceptions

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

$30 copay/visit

$60 copay/visit

50% subject to deductible

None

Specialist visit

$60 copay/visit

$145 copay/visit

50% subject to deductible

None

Other practitioner office visit

$30 copay/visit

$60 copay/visit

50% subject to deductible

None

Preventive care/ screening/immunization

No charge

No charge

50% subject to deductible

Immunizations are excluded except for those recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC).

If you have a test

Diagnostic test (x-ray, blood work)

$40 copay/visit

$80 copay/visit

50% subject to deductible

Includes outpatient Lab tests, x-ray, pathology, imaging/diagnostic testing. Genetic testing requires precertification and will only be covered if Medically Necessary as determined by a Physician.

Imaging (CT/PET scans, MRIs) 

$300 copay/service

$600 copay/service

50% subject to deductible

Precertification required.

If you need drugs to treat your illness or
condition
 
More information about prescription drug coverage
is available at
www.landoflin colnhealth.org /shop-forplans/formula
ry

Formulary Low-Cost Generic drugs

Retail: $4
copay/prescription Mail-Order: $10 copay/prescription

Retail: $4
copay/prescription Mail-Order: $10 copay/prescription

50% subject to deductible

Covers up to a 34-day supply (retail prescription); 90-day supply (Mail-Order prescription).

Prior Authorization, Step Therapy or Quantity Limits may apply. 

For a full list of covered drugs (formulary prescriptions) and/or services, please contact Member Services, or refer to the Pharmacy formulary at www.landoflincolnhealth.org/shop-forplans/formulary.

Formulary Generic drugs

Retail: $20
copay/prescription Mail-Order: $50 copay/prescription

Retail: $20
copay/prescription Mail-Order: $50 copay/prescription

50% subject to deductible

Formulary Preferred Brand drugs

Retail: $50 copay/prescription Mail-Order: $125 copay/prescription

Retail: $50 copay/prescription Mail-Order: $125 copay/prescription

50% subject to deductible

Formulary Non-
Preferred Brand drugs

Retail: 25% subject to deductible Mail-Order: 25% subject to deductible

Retail: 25% subject to deductible Mail-Order: 25% subject to deductible

50% subject to deductible

Formulary Specialty
Generic & Preferred
Brand drugs

Retail: 25% subject to deductible Mail-Order: 25% subject to deductible

Retail: 25% subject to deductible Mail-Order: 25% subject to deductible

50% subject to deductible

Not all specialty drugs are covered and prior authorization may be required. Specialty drugs must be filled through LLH’s specialty drug pharmacy – Briova Network. See your policy documents for details.

Formulary Specialty Non-Preferred Brand drugs 

Retail: 50% subject to deductible Mail-Order: 50% subject to deductible

Retail: 50% subject to deductible Mail-Order: 50% subject to deductible

50% subject to deductible

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

25% subject to deductible

45% subject to deductible

50% subject to deductible

Precertification required.

Physician/surgeon fees

25% subject to deductible

45% subject to deductible

50% subject to deductible

Precertification required.

If you need immediate medical attention

Emergency room
services

$500 copay/visit

$500 copay/visit

$500 copay/visit

Notification required within 2 business days.

Emergency medical transportation

$500 copay/service

$500 copay/service

50% subject to deductible

None

Urgent care 

$60 copay/visit

$60 copay/visit

50% subject to deductible

None

If you have a hospital stay

Facility fee (e.g., hospital room)

$850 copay/day for first 3 days

$1,800 copay/day for first 3 days

50% subject to deductible

Based on the semi-private room rate. Excludes patient convenience items. Precertification required.

Physician/surgeon fee

25% subject to deductible

45% subject to deductible

50% subject to deductible

Precertification required.

If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services

$30 copay/visit

$30 copay/visit

50% subject to deductible

Precertification not required for office visits for
outpatient therapy or medical management. Precertification is required for all other outpatient services. See policy for details.

Mental/Behavioral health inpatient services

$850 copay/day for first 3 days

$1,800 copay/day for first 3 days

50% subject to deductible

Precertification required.

Substance use disorder outpatient services

$30 copay/visit

$30 copay/visit

50% subject to deductible

Precertification not required for office visits for
outpatient therapy or medical management. Precertification is required for all other outpatient services. See policy for details.

Substance use disorder inpatient services

$850 copay/day for first 3 days

$1,800 copay/day for first 3 days

50% subject to deductible

Precertification required.

If you are pregnant

Prenatal and postnatal care

$30 copay/visit

$60 copay/visit

50% subject to deductible

Notification is required upon confirmation of pregnancy. 

Delivery and all inpatient services

$850 copay/day for first 3 days

$1,800 copay/day for first 3 days

50% subject to deductible

If you need help recovering or have other special health needs

Home health care

$75 copay/visit

$300 copay/visit

50% subject to deductible

Precertification required. Limited to 45 days per year.

Rehabilitation services

$65 copay/visit

$130 copay/visit

50% subject to deductible

These services apply to Physical, Occupational, Nutrition and Speech therapies. Precertification and Periodic Review required.

Habilitation services

$65 copay/visit

$130 copay/visit

50% subject to deductible

Precertification required.

Skilled nursing care

$100 copay/day

$400 copay/day

50% subject to deductible

Precertification required. Limited to 45 days per year.

Durable medical equipment

25% subject to deductible

45% subject to deductible

50% subject to deductible

Precertification required.

Hospice service

25% subject to deductible

45% subject to deductible

50% subject to deductible

Precertification required. Limited to Insured Persons that have a Terminal Illness with a life expectancy of 1 year or less.

If your child needs dental or eye care

Eye exam

No charge

No charge

50% subject to deductible

Limited to one exam per year for Insured Dependent children under age 19.

Glasses

No charge

No charge

50% subject to deductible

Limited to one pair of glasses per year for Insured Dependent children under age 19.

Dental check-up

No charge

No charge

50% subject to deductible

Limited to one check-up every six months for Insured Dependent children under age 19.

Important Questions

Answers

Why this Matters:

What is the overall deductible?

Integrated In-Network Tier 1/Tier 2: $500 individual / $1,000 family 
Out-of-Network: $6,000 individual / $12,000 family Doesn’t apply to preventive care.

You must pay all the costs up to the deductibleamount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductiblestarts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. In-Network Tier 1/Tier 2 deductible is one integrated deductible. It is separate for the Out-of-Network Deductible.

Are there other deductibles for specific services?

No.  

You don’t have to meet deductibles for specific services but see the chart starting on page 2 for other costs for services this plan covers.

Is there an Out–of–Pocket limit on my expenses?

Yes.  For In-Network Tier 1/Tier 2 providers: $6,800 individual / $13,600 family
For Out-of-Network providers: Unlimited individual
/ Unlimited family

The Out-of-Pocket limitis the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. In-Network Tier 1/Tier 2 Annual Out-of-Pocket limits are one integrated Out-of-Pocket limit and is separate from Out-of-Network Annual Out-of-Pocket limit.

What is not included in the Out–of–Pocket limit?

Premiums, balance-billed charges, and health care this plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the Out-of-Pocket limit. 

Is there an overall annual limit on what the plan pays?

No. 

The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.

Does this plan use a network of providers?

Yes. See www.landoflincolnhealth.org/find-a-doctoror call 1-844-674-3834 for a list of participating providers.

If you use an In-Network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your In-Network doctor or hospital may use an Out-of-Network provider for some services. Plans use the term In-Network or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. 

Do I need a referral to see a specialist?

No. 

You can see the specialistyou choose without permission from this plan.

Are there services this plan doesn’t cover?

Yes.

Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services.

Services You May Need

Your Cost If You Use an In-Network Tier 1 Provider

Your Cost If You Use an In-Network Tier 2 Provider

Your Cost If You Use an Out-of-Network Provider

Limitations & Exceptions

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

$10 copay/visit

$40 copay/visit

50% subject to deductible

None

Specialist visit

$40 copay/visit

$75 copay/visit

50% subject to deductible

None

Other practitioner office visit

$10 copay/visit

$40 copay/visit

50% subject to deductible

None

Preventive care/ screening/immunization

No charge

No charge

50% subject to deductible

Immunizations are excluded except for those recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC).

If you have a test

Diagnostic test (x-ray, blood work)

$15 copay/visit

$60 copay/visit

50% subject to deductible

Includes outpatient Lab tests, x-ray, pathology, imaging/diagnostic testing. Genetic testing requires precertification and will only be covered if Medically Necessary as determined by a Physician.

Imaging (CT/PET scans, MRIs) 

$250 copay/service

$400 copay/service

50% subject to deductible

Precertification required.

If you need drugs to treat your illness or
condition
 
More information about prescription drug coverage
is available at
www.landoflin colnhealth.org /shop-forplans/formula
ry

Formulary Low-Cost Generic drugs

Retail: $0
copay/prescription Mail-Order: $0 copay/prescription

Retail: $0
copay/prescription Mail-Order: $0 copay/prescription

50% subject to deductible

Covers up to a 34-day supply (retail prescription); 90-day supply (Mail-Order prescription).

Prior Authorization, Step Therapy or Quantity Limits may apply. 

For a full list of covered drugs (formulary prescriptions) and/or services, please contact Member Services, or refer to the Pharmacy formulary at www.landoflincolnhealth.org/shopfor-plans/formulary.

Formulary Generic drugs

Retail: $15 copay/prescription Mail-Order: $37.50 copay/prescription

Retail: $15 copay/prescription Mail-Order: $37.50 copay/prescription

50% subject to deductible

Formulary Preferred Brand drugs

Retail: $35 copay/prescription Mail-Order: $87.50 copay/prescription

Retail: $35 copay/prescription Mail-Order: $87.50 copay/prescription

50% subject to deductible

Formulary Non-
Preferred Brand drugs

Retail: $75 copay/prescription Mail-Order: $187.50 copay/prescription

Retail: $75 copay/prescription Mail-Order: $187.50 copay/prescription

50% subject to deductible

Formulary Specialty
Generic & Preferred
Brand drugs

Retail: 20% subject to deductible Mail-Order: 20% subject to deductible

Retail: 20% subject to deductible Mail-Order: 20% subject to deductible

50% subject to deductible

Not all specialty drugs are covered and prior authorization may be required. Specialty drugs must be filled through LLH’s specialty drug pharmacy – Briova Network. See your policy documents for details.

Formulary Specialty Non-Preferred Brand drugs 

Retail: 50% subject to deductible Mail-Order: 50% subject to deductible

Retail: 50% subject to deductible Mail-Order: 50% subject to deductible

50% subject to deductible

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

20% subject to deductible

40% subject to deductible

50% subject to deductible

Precertification required.

Physician/surgeon fees

20% subject to deductible

40% subject to deductible

50% subject to deductible

Precertification required.

If you need immediate medical attention

Emergency room
services

$500 copay/visit

$500 copay/visit

$500 copay/visit

Notification required within 2 business days.

Emergency medical transportation

$500 copay/service

$500 copay/service

50% subject to deductible

None

Urgent care 

$60 copay/visit

$60 copay/visit

50% subject to deductible

None

If you have a hospital stay

Facility fee (e.g., hospital room)

$400 copay/day for first 3 days

$900 copay/day for first 3 days

50% subject to deductible

Based on the semi-private room rate. Excludes patient convenience items. Precertification required.

Physician/surgeon fee

20% subject to deductible

40% subject to deductible

50% subject to deductible

Precertification required.

If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services

$10 copay/visit

$10 copay/visit

50% subject to deductible

Precertification not required for office visits for outpatient therapy or medical management. Precertification is required for all other outpatient services. See policy for details.

Mental/Behavioral health inpatient services

$400 copay/day for first 3 days

$900 copay/day for first 3 days

50% subject to deductible

Precertification required.

Substance use disorder outpatient services

$10 copay/visit

$10 copay/visit

50% subject to deductible

Precertification not required for office visits for outpatient therapy or medical management. Precertification is required for all other outpatient services. See policy for details.

Substance use disorder inpatient services

$400 copay/day for first 3 days

$900 copay/day for first 3 days

50% subject to deductible

Precertification required.

If you are pregnant

Prenatal and postnatal care

$10 copay/visit

$40 copay/visit

50% subject to deductible

Notification is required upon confirmation of pregnancy. 

Delivery and all inpatient services

$400 copay/day for first 3 days

$900 copay/day for first 3 days

50% subject to deductible

If you need help recovering or have other special health needs

Home health care

$50 copay/visit

$150 copay/visit

50% subject to deductible

Precertification required. Limited to 45 days per year.

Rehabilitation services

$35 copay/visit

$105 copay/visit

50% subject to deductible

These services apply to Physical, Occupational, Nutrition and Speech therapies. Precertification and Periodic Review required.

Habilitation services

$35 copay/visit

$105 copay/visit

50% subject to deductible

Precertification required.

Skilled nursing care

$50 copay/day

$150 copay/day

50% subject to deductible

Precertification required. Limited to 45 days per year.

Durable medical equipment

20% subject to deductible

40% subject to deductible

50% subject to deductible

Precertification required.

Hospice service

20% subject to deductible

40% subject to deductible

50% subject to deductible

Precertification required. Limited to Insured Persons that have a Terminal Illness with a life expectancy of 1 year or less.

If your child needs dental or eye care

Eye exam

No charge

No charge

50% subject to deductible

Limited to one exam per year for Insured Dependent children under age 19.

Glasses

No charge

No charge

50% subject to deductible

Limited to one pair of glasses per year for Insured Dependent children under age 19.

Dental check-up

No charge

No charge

50% subject to deductible

Limited to one check-up every six months for Insured Dependent children under age 19.