| Overview | Red Plan | |
| White Plan | Blue Plan |
White Plan
Download the White Plan benefit information.
| BENEFITS | In-Panel | Out-of-Panel |
| Annual Deductible (person/family) | $250/$500 | $500/$1,000 |
| Primary Physician Office Visit Copay (Family Practitioner, Internist, Pediatrics, Ob-Gyn) | $15 | 60% of UCR after ded. |
| Specialist Office Visit Copay (Excluding Mental Illness, Substance Abuse, Surgery or Pregnancy) | $25 | 60% of UCR after ded. |
| Coinsurance | 80% after ded. | 60% of UCR after ded. |
| Annual Out-of-Pocket Coinsurance Limit |
$1,000/person $2,000/family |
$3,000/person $6,000/family |
| Emergency Room Visit for Emergency Accident/Emergency Medical Services (Access Fee waived with Admission) |
80% $50 Copayment per visit |
80% $50 Copayment per visit in addition to the deductible |
| Lifetime Benefit Maximums Lifetime | $2,000,000/person | $2,000,000/person |
| Substance Abuse |
90 day inpatient 150 outpatient visits |
90 day inpatient 150 outpatient visits |
| Hospice | $5,000/person | $5,000/person |
| COVERED SERVICES | ||
| Preventive Care: Routine adult physical exams and Well Child Care* | 100% after $15 Copay | Not Covered |
| Immunizations | 100% | 100% |
| Mammograms | 100% | 60% |
| Inpatient Facility Care | 80% after ded. | 60% of UCR after ded. and $100 Copay/admission |
| Hospital/Surgical | 80% after ded. | 60% of UCR after ded. and $100 Copay/admission |
| Outpatient or Ambulatory Surgery | 80% after ded. | 60% of UCR after ded. |
| Maternity | 80% after ded. | 60% of UCR after ded. Plus $100 Copayment for maternity admission |
| Skilled Nursing Facility | 80% after ded. | 60% of UCR after ded. |
| Home Health Care | 80% after ded. | 60% of UCR after ded. |
| Hospice Care for Individuals expected to live less than 6 months | 80% after ded. | 60% of UCR after ded. |
| Rehabilitation Service (Occupational, physical and speech therapies) | 80% after ded. | 60% of UCR after ded. |
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Other Services (incl. diagnostic, x-ray & lab) Infertility (Initial office visit & blood work only) |
80% after ded. | 60% of UCR after ded. |
| Manipulative Therapy ** | $25 Copay/visit | 60% of UCR after ded. |
| Mental Health (calendar year) |
80% after ded. 30 days - inpatient 30 visits - outpatient |
60% of UCR after ded. 30 days - inpatient (& $100 Copayment per admission) 30 visits - outpatient |
| Substance Abuse (calendar year) |
80% after ded. 30 days -inpatient 30 visits - outpatient |
60% of UCR after ded. 30 days - inpatient (& $100 Copayment per admission) 30 visits - outpatient |
| Diagnostic, X-Ray, & Lab (Optional) | 100% | N/A |
| Prescription Plan |
$0 Deductible $100 Deductible per individual (optional) Retail Co-Payments: - $15 generic - $25 Preferred Brand - $50 non-preferred Mail Order Co-Payments: - $30 generic - $50 Preferred Brand - $100 non-preferred Coinsurance - N/A Retail Supply Limit: 34 day supply or 100 tablets whichever is greater Mail Order Supply Limit: 90 day supply |
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* Routine Adult Physical Exam = Maximum 1 exam/yr for medical (Primary Care Physician Only) ** Manipulative Therapy: 20 Visits per year for subluxations demonstrable by x-ray. Maximum $500 per calendar year. + When not treated by a Panel Provider, you are responsible for any Precertification required by your plan. Failure to obtain precertification may result in reduced benefits. This is a summary of principal provisions of the Agreement between your group and ICHP as regulated by PA Insurance laws. The Member Certificate of Insurance should be consulted to determine the governing provisions. |
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