Important Questions

Answers

Why this Matters:

What is the overall deductible?

In-Network: $1,900 individual / $3,800 family 
Out-of-Network: $8,000 individual / $16,000 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.

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 providers: $6,500 individual / $13,000 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.

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 Outof-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-doctor or 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 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% subject to deductible

50% subject to deductible

None

Specialist visit

30% subject to deductible

50% subject to deductible

None

Other practitioner office visit

30% subject to deductible

50% subject to deductible

None

Preventive care/screening/ immunization

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 (xray, blood work)

30% subject to deductible

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) 

30% subject to deductible

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.landoflincoln
health.org/shopforplans/formulary

Formulary LowCost Generic drugs

Retail: 30% subject to deductible Mail-Order: 30% subject to deductible

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: 30% subject to deductible Mail-Order: 30% subject to deductible

50% subject to deductible

Formulary Preferred Brand drugs

Retail: 30% subject to deductible Mail-Order: 30% subject to deductible

50% subject to deductible

Formulary Non-
Preferred Brand drugs

Retail: 30% subject to deductible Mail-Order: 30% subject to deductible

50% subject to deductible

Formulary
Specialty Generic & Preferred Brand drugs

Retail: 30% subject to deductible Mail-Order: 30% 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 NonPreferred Brand drugs 

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)

30% subject to deductible

50% subject to deductible

Precertification required. 

Physician/surgeon fees

30% subject to deductible

50% subject to deductible

Precertification required. 

If you need immediate medical attention

Emergency room
services

30% subject to deductible

30% subject to deductible

Notification required within 2 business days.

Emergency medical transportation

30% subject to deductible

50% subject to deductible

None

Urgent care 

30% subject to deductible

50% subject to deductible

None

If you have a hospital stay

Facility fee (e.g., hospital room)

30% subject to deductible

50% subject to deductible

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

Physician/surgeon fee

30% 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% subject to deductible

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

30% subject to deductible

50% subject to deductible

Precertification required.

Substance use disorder
outpatient services

30% subject to deductible

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

30% subject to deductible

50% subject to deductible

Precertification required.

If you are pregnant

Prenatal and postnatal care

30% subject to deductible

50% subject to deductible

Notification is required upon confirmation of pregnancy. 

Delivery and all inpatient services

30% subject to deductible

50% subject to deductible

If you need help recovering or have other special health needs

Home health care

30% subject to deductible

50% subject to deductible

Precertification required. Limited to 45 days per year.

Rehabilitation services

30% subject to deductible

50% subject to deductible

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

Habilitation services

30% subject to deductible

50% subject to deductible

Precertification required. 

Skilled nursing care

30% subject to deductible

50% subject to deductible

Precertification required. Limited to 45 days per year.

Durable medical equipment

30% subject to deductible

50% subject to deductible

Precertification required.

Hospice service

30% 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

50% subject to deductible

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

Glasses

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

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?

In-Network: $1,350 individual / $2,700 family 
Out-of-Network: $5,000 individual / $10,000 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.

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 providers: $3,300 individual / $6,600 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.

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 Outof-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-doctor or 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 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

20% subject to deductible

50% subject to deductible

None

Specialist visit

20% subject to deductible

50% subject to deductible

None

Other practitioner office visit

20% subject to deductible

50% subject to deductible

None

Preventive care/screening/ immunization

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 (xray, blood work)

20% subject to deductible

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) 

20% subject to deductible

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.landoflincoln
health.org/shopforplans/formulary

Formulary Low-
Cost Generic drugs

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

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

50% subject to deductible

Formulary Preferred Brand drugs

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

50% subject to deductible

Formulary Non-
Preferred Brand drugs

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

50% subject to deductible

Formulary Specialty
Generic & Preferred Brand drugs

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

50% subject to deductible

If you have outpatient surgery

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

20% subject to deductible

50% subject to deductible

Precertification required. 

Physician/surgeon fees

20% subject to deductible

50% subject to deductible

Precertification required. 

If you need immediate medical attention

Emergency room
services

20% subject to deductible

20% subject to deductible

Notification required within 2 business days.

Emergency medical transportation

20% subject to deductible

50% subject to deductible

None

Urgent care 

20% subject to deductible

50% subject to deductible

None

If you have a hospital stay

Facility fee (e.g., hospital room)

20% subject to deductible

50% subject to deductible

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

Physician/surgeon fee

20% 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

20% subject to deductible

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

20% subject to deductible

50% subject to deductible

Precertification required.

Substance use disorder outpatient services

20% subject to deductible

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

20% subject to deductible

50% subject to deductible

Precertification required.

If you are pregnant

Prenatal and postnatal care

20% subject to deductible

50% subject to deductible

Notification is required upon confirmation of pregnancy. 

Delivery and all inpatient services

20% subject to deductible

50% subject to deductible

If you need help recovering or have other special health needs

Home health care

20% subject to deductible

50% subject to deductible

Precertification required. Limited to 45 days per year.

Rehabilitation services

20% subject to deductible

50% subject to deductible

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

Habilitation services

20% subject to deductible

50% subject to deductible

Precertification required. 

Skilled nursing care

20% subject to deductible

50% subject to deductible

Precertification required. Limited to 45 days per year.

Durable medical equipment

20% subject to deductible

50% subject to deductible

Precertification required.

Hospice service

20% 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

50% subject to deductible

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

Glasses

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

50% subject to deductible

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