Annual deductible
When you see providers in the Extended network, each dependent only needs to meet the individual deductible before the Plan starts paying coinsurance for that family member. And, once you meet
the family deductible, the Plan pays coinsurance for the whole family, even those who haven't met their individual deductible, up to the out-of-pocket maximum.
Your out-of-pocket maximum works in the same way: each family member can reach their individual out-of-pocket max, and you can reach the family out-of-pocket max without reaching each individual's
out-of-pocket max.
Once you reach your out-of-pocket max, the Plan pays for the full cost of care.
|
None |
$1,000 per person; $3,000 per family, shared with Out-of-network |
$1,000 per person; $3,000 per family, shared with Extended network |
| Copayments |
$20 PCP visit; $40 specialist/other office visit |
Not applicable |
Not applicable |
| Annual out-of-pocket maximum |
$2,000 per person; $6,000 family |
| Amount plan pays for covered services |
| Air Ambulance |
90% |
90%, deductible does not apply |
90% of allowable charges, deductible does not apply |
| Ambulance (ground or water) |
90% |
90%, deductible does not apply |
90%, deductible does not apply |
| Autism/ABA therapy |
90% |
90%, deductible does not apply |
50% of allowable charges, after deductible |
| Chiropractic, massage, and acupuncture services (when medically necessary) |
100% after $40 copay; deductible does not apply |
50% of allowable charges, after deductible |
| Combined 24-visit limit per year for Health Connect, Extended, and Out-of-network |
| Contraception |
100% |
100%, deductible does not apply |
50% of allowable charges, after deductible |
| Diabetes health education |
100% |
100%, deductible does not apply |
50% of allowable charges, after deductible |
| Emergency room care & professional services |
100% after $250 copay (waived if admitted) |
| Home health care |
90% |
60% after deductible |
50% of allowable charges, after deductible |
| Hospice care |
90% |
60% after deductible |
50% after deductible |
| Hospital inpatient and outpatient |
90% |
60% after deductible |
50% of allowable charges, after deductible |
| Infertility |
90% of covered benefits, within the Progyny provider network |
Not applicable |
Not applicable |
| Lab tests and X-rays |
90% |
90%, deductible does not apply |
50% of allowable charges, after deductible |
| Maternity care |
90% |
60% after deductible |
50% of allowable charges, after deductible |
| Maternity care bundle (Routine pregnancy and delivery care received within the Health Connect network)
|
$500 copay |
Not applicable |
Not applicable |
| Doula services |
Maximum benefit of $1,000 per pregnancy |
| Medical equipment and supplies |
90% |
90%, deductible does not apply |
50% of allowable charges, after deductible |
Mental health, attention deficit disorder, and substance use disorder treatment
*In no event will the outpatient copay exceed 40% of the allowed amount. |
Inpatient: 90%
Outpatient: 100% after $20 copay per visit |
Inpatient: 90%, deductible does not apply
Outpatient: 100% after $20 copay* per visit, deductible does not apply |
Inpatient: 90% of allowable charges, deductible does not apply
Outpatient: 90% of allowable charges, deductible does not apply |
Microsoft CARES
Employee Assistance Program |
100% of 24 sessions per calendar year |
Not covered |
| Office visit |
PCP visit: 100% after $20 copay
Specialist/other office visit: 100% after $40 copay |
Office visit: 60% after deductible
Specialist/other office visit: 60% after deductible |
Office visit: 50% of allowable charges, after deductible
Specialist/other office visit: 50% of allowable charges, after deductible |
| Prescription drugs—Retail |
Generic: 100% after $10 copay, deductible does not apply
Brand preferred: 100% after $30 copay, deductible does not apply
Brand non-preferred: 100%
after $60 copay, deductible does not apply
Check the Health Connect Plan drug formulary
|
Generic: 50% of allowable charges, deductible does not apply
Brand preferred: 50% of allowable charges, deductible does not apply
Brand non-preferred: 50%
of allowable charges, deductible does not apply |
Prescription drugs—Mail order
(90-day supply) |
Generic: 100% after $20 copay, deductible does not apply
Brand preferred: 100% after $60 copay, deductible does not apply
Brand non-preferred: 100%
after $120 copay, deductible does not apply
Check the Health Connect Plan drug formulary
|
Not covered |
Prescription drugs – Specialty (30-day supply)
through Accredo Specialty Pharmacy or Walgreen’s Specialty Pharmacy
|
Specialty Brand preferred: 100% after $30 copay, deductible does not apply
|
Specialty Brand non-preferred: 100% after $60 copay, deductible does not apply
|
Not covered
|
| Preventive care |
Preventive services: 100%, deductible does not apply
Preventive generic prescription drugs: 100%, deductible does not apply
Check the preventive care services list
Check the preventive drug list
|
Preventive services: 50% of allowable charges, after deductible
Preventive generic prescription drugs: 50% of allowable charges, deductible does not apply
|
| Routine hearing exam and hardware |
Exam: 100% after $40 copay |
Exam: 100% after $40 copay |
Exam: 50% of allowable charges, after deductible |
| Hardware: 90% up to $10,000 maximum benefit per member in a period of three consecutive calendar years |
| Skilled nursing facility (120-day maximum per calendar year) |
90% |
60% after deductible |
50% of allowable charges, after deductible |
| Urgent care |
100% after $40 copay |
60% after deductible |
50% of allowable charges, after deductible |
| Virtual care |
Mental health and substance use disorder treatment: 100%
Other services: 100% |
Mental health and substance use disorder treatment: 100%
Other services: 60% after deductible |
Mental health and substance use disorder treatment: 100% of allowable charges, deductible does not apply
Other services: 50% of allowable charges, after deductible |