Washwick
PLANS

Plan 1 HMO

$637.07Single

$1258.14 Employee & Spouse

$1258.14 Employee & Child(ren)

$1812.94Family

Plan 2 HMO

$537.49 Single

$989.60 Employee & Spouse $1058.98

Employee & Child(ren)

$1524.83 Family

Plan 3 HMO

$502.80 Single

$989.60Employee & Spouse

$989.60Employee & Child(ren)

$1424.46 Family

Plan 4 POS

$618.02Single

$1220.04 Employee & Spouse

$1220.04 Employee & Child(ren)

$1757.82 Family

DEDUCTIBLE

None

None

None

In Network: $0;
Out of Network: $2000 Single / $4000 Family; You pay 30% of expense until you reach an out of Pocket max of $5000/$10000

Deductible is Calendar Year

Office/Specialist Visits

$20

$25/40

$25/40

In-network: $25/$40;

Out of Network: Subject to deductible and co-insurance

Prescriptions

$20/$30/$40

$20/$30/$40
Mandatory Generic

$20/$30/$40

Hospital Copay

$0

$500
$500

In Patient: $500;

Out of Network: Subject to deductible and co-insurance

ER Copay

$50

$50

$50

In Patient: $50;

Out of Network: Subject to deductible and co-insurance
Allergy Testing

$20

$25

$25

In Patient: $25;

Out of Network: Subject to deductible and co-insurance

Anesthesia

$0
$25
$25

In Patient: $0;

Out of Network: Subject to deductible and co-insurance
Diagnostic Services
$20
$25
$25

In Patient: $25;

Out of Network: Subject to deductible and co-insurance
Mammography
$20
$25
$25

In Patient: $25;

Out of Network: Subject to deductible and co-insurance
OB/GYN
$20
$25
$25

In Patient: $25;

Out of Network: Subject to deductible and co-insurance
Pap Smears
$20
$25
$25

In Patient: $25;

Out of Network: Subject to deductible and co-insurance
2nd Opinions
$20
$25
$25

In Patient: $25;

Out of Network: Subject to deductible and co-insurance
Periodic Adult Physicals
$20
$25
$25
$25 IN PATIENT ONLY
Well Child Care (Incl. immunizations)
$0
$0
$0

$0 IN PATIENT ONLY
Pre & Post Natal Care
$20
$25
$25

In Patient: $25;

Out of Network: Subject to deductible and co-insurance
Chiropractic
$20
$40
$40

In Patient: $40;

Out of Network: Subject to deductible and co-insurance
Delivery of Child
$0
Lesser of 20% or $200
Lesser of 20% or $200

In Patient: $0;

Out of Network: Subject to deductible and co-insurance
Radiation & Chemotherapy
$20
$25
$25

In Patient: $25;

Out of Network: Subject to deductible and co-insurance
Hemodialysis
$20
$25
$25

In Patient: $25;

Out of Network: Subject to deductible and co-insurance
Pre-admission testing
$20
$25
$25

In Patient: $25;

Out of Network: Subject to deductible and co-insurance
X-rays & Labs
$20
$25
$25

In Patient: $25;

Out of Network: Subject to deductible and co-insurance
Outpatient Surgery Facility
$0
$75
$75
In Patient: Lesser of 20% or $200; Out of Network: Subject to deductible and co-insurance
Blood & Blood Products
$0
$0
$0

In Patient: $0;

Out of Network: Subject to deductible and co-insurance
Ambulance Services
$0
$50
$75

In Patient: $50;

Out of Network: Subject to deductible and co-insurance
Skilled Nursing
$0 45 days per calendar year
$500 30 days per calendar year
$500 30 days per calendar year

In Patient: $500 45 days per calendar year;

Out of Network: Subject to deductible and co-insurance
Home Health Care
$0 60 visits per calendar year
$25 40 visits per calendar year
$25 40 visits per calendar year

In Patient: $25 per day 60 visits per calendar year;

Out of Network: Subject to deductible and co-insurance
In-patient Hospice (210 days combined w/ outpatient)
$0
$0
$0

In Patient: $0;

Out of Network: Subject to deductible and co-insurance
Out-patient Hospice
$0
$0
$0

In Patient: $0;

Out of Network: Subject to deductible and co-insurance
Inpatient Physical, Speech, Occupational Therapy
$0 limited to 30 days per diagnosis per calendar year
$500 limited to 10 days per diagnosis per calendar year
$500 limited to 10 days per diagnosis per calendar year

In Patient: $500 30 days per diagnosis per calendar year;

Out of Network: Subject to deductible and co-insurance
Outpatient Physical, Speech, Occupational Therapy
$0 limited to 20 visits per diagnosis per calendar year
$40 limited to 20 visits per diagnosis per calendar year (only following inpatient stay)
$40 limited to 20 visits per diagnosis per calendar year (only following inpatient stay)

In Patient: $40 20 visits per diagnosis per calendar year (only following inpatient stay);

Out of Network: Subject to deductible and co-insurance
Inpatient Mental Health (per continuous confinement) (30 days per calendar year)
$0
$500
$500

In Patient: $500;

Out of Network: Subject to deductible and co-insurance
Outpatient Mental Health (20 visits per calendar year)
$0
$40
$40

In Patient: $40;

Out of Network: Subject to deductible and co-insurance
Inpatient Detox (per continuous confinement) (limited to 7 days per calendar year)
$0
$500
$500

In Patient: $0;

Out of Network: Subject to deductible and co-insurance
Outpatient Rehab (60 visits per calendar year (20 of the visits may be used for Family Therapy)
$0
$40
$40

In Patient: $40;

Out of Network: Subject to deductible and co-insurance
Durable Medical Equipment & Supplies
$0
20% co-insurance
20% co-insurance

In Patient: $25;

Out of Network: Subject to deductible and co-insurance
Diabetic Equipment & Supplies
$20 per item or 34 day supply
$25
$25

In Patient: $25 copay per item or 34 day supply;

Out of Network: Subject to deductible and co-insurance
Dependants

Covered to 19 EOM unless full time student, thrn 23 EOM. 

Domestic Partners eligible for coverage at RENEWAL

Covered to 19 EOM unless full time student, thrn 23 EOM.

Domestic Partners eligible for coverage at RENEWAL

Covered to 19 EOM unless full time student, thrn 23 EOM.

Domestic Partners eligible for coverage at RENEWAL

Covered to 19 EOM unless full time student, thrn 23 EOM.

Domestic Partners not covered.

Rates & Benefits are for comparative purposes only. 
Atlantis has become the Easy Choice Health Plan of New York. Actual rate & benefit info and details must come directly from the insurance carrier.

This is only a summary of benefits. You will receive full details of coverage contained in the policy received directly from Insurance Company. If there is any conflict between the contents of this document/website and the policy from the Insurance Company, the Policy will govern in all cases.

  $16 Administrative Fee Incl.

Rates Effective 11/1/2010 to 10/31/2011