HMSA CompMED Choice – A PPO Health Plan
Deductible (per calendar year)
Single: $200
Family: $600
Max-out-of-pocket (per calendar year)
Single: $2,200
Family: $6,600
Medical Services
| wcagcolheader | You Pay |
|---|---|
| Routine physical exams | $0* |
| Screening mammography | $0* |
| Immunizations | $0* |
| Well-baby care visits | $0* |
| Maternity (Hospital Room & Board) | 20% |
| Primary care office visit | $12 |
| Consultations | $12 |
| Emergency room care | 20% |
| Ambulance | 20% |
| Inpatient room and board | 20% |
| Inpatient and outpatient surgery | 20% |
| Chemotherapy/radiation therapy | 20% |
| Diagnostic X-ray | 20% |
| Durable medical equipment | 20% |
| Physical and occupational therapy | $12 |
| Inpatient care | 20%, facility services |
| Outpatient care | 20%, facility services |
*Not subject to deductible.
Plan resources
Prescription Drug Program
Max-out-of-pocket (per calendar year)
Single: $3,600
Family: $4,200
| wcagcolheader | 30-Day Retail Supply You Pay |
90-Day Retail Supply You Pay |
90-Day Mail Order Supply You Pay |
|---|---|---|---|
| Tier 1 (mostly Generic) | $7 | $11 | $11 |
| Tier 2 (mostly Preferred Brand) | $30 | $65 | $65 |
| Tier 3 (mostly Other Brand) | $30 plus $45 Tier 3 cost share | $65 plus $135 Tier 3 cost share | $65 plus $135 Tier 3 cost share |
| Tier 4 (mostly Preferred Specialty) | $100 | Not available | Not available |
| Tier 5 (mostly Other Brand Specialty) | $200 | Not available | Not available |
Plan resources
Vision Care Services for Adults
| wcagcolheader | You Pay |
|---|---|
| Eye examination (one per calendar year) |
$10 |
| Lenses (one of the following per calendar year) |
|
| Frames (one frame every 24 months) |
$15 |
| Contact lens fitting (one per calendar year) |
All charges after the plan pays $45 |
