The Gold 1 Plan provides strong coverage, affordable copays, and full access to
our provider network.
Hospitalization – No Authorization
Protection Against Excess Costs
Provider and pharmacy network
No-cost preventive care
Click any category to see detailed copays and coverage.
Total maximum out-of-pocket expenses per year
Immediate emergency care
Consultations and treatments without hospitalization
Diagnostic tests and medical studies
Hospital stays and inpatient care
Therapies and necessary medical equipment
Group therapy and emotional support
Covered prescription medications
Preventive care and ongoing management
Exams, lenses, and vision benefits
Adult Vision, Air Ambulance, coverage in the U.S.
Procedure for severe obesity management
Diagnosis, prevention, and dental treatments
Total maximum out-of-pocket expenses per year
| Individual | $6,350 |
| Family | $12,700 |
Immediate emergency care
| Accident | FR $50 / PR $30 |
| Illness | FR $50 / PR $30 |
Consultations and treatments without hospitalization
| Primary Care Physician | $7 |
| Specialist | $15 |
| Sub-Specialist | $20 |
| Psychiatrist | $15 |
| Psychologist | $15 |
| Podiatrist | $15 |
| Chiropractor | $15 |
| Audiologist | $15 |
| Optometrist | $15 |
| Nutritionist | Reimbursement up to $20 per visit, 4 per year |
| Ambulatory Surgery Center | FR $150 / PR $0 |
| In-Office Diagnostic / Surgical Procedures | 50% |
| Endoscopic Procedures | 50% |
Diagnostic tests and medical studies
| Laboratory | FR 30% / PR 0% |
| X-Ray | FR 30% / PR 0% |
| PET Scan, CT Scan, MRI, or PET CT (1 year) | 50% |
Hospital stays and inpatient care
| Partial including Mental Health | $100 |
| Full with Pre-authorization including Mental Health | FR $150 / PR $0 |
| Full without Pre-authorization including Mental Health | FR $150 / PR $0 |
| Skilled Nursing Facilities | 35% |
| Surgical Assistance | Subscriber pays 50% |
Therapies and necessary medical equipment
| Physical Therapy | $7 |
| Respiratory Therapy | $7 |
| Home Health Care | 50% |
| Durable Medical Equipment | 50% up to $5,000, Excess 80% |
| Chiropractic Manipulations | $7 |
Group therapy and emotional support
| Group Therapy | $15 |
| Collateral Visits | $15 |
Covered prescription medications
| Pharmacy Benefit | $0–$800: copays and coinsurance apply; $801+: 80% coinsurance |
| Generic Bioequivalent | $5 for $0–$800; $801+: 80% |
| Preferred Brand | 25% for $0–$800; $801+: 80% |
| Non-Preferred Brand | 50% for $0–$800; $801+: 80% |
| Specialty Products | 50% for $0–$800; $801+: 80% |
| Over-the-Counter (OTC) Medications | Not Covered |
Preventive care and ongoing management
| Preventive Services | 0% |
| Preventive Vaccinations | 0% |
| Respiratory Syncytial Virus (RSV) Vaccine | 35% |
Exams, lenses, and vision benefits
| Eye Exam (Refraction) | $0 |
| Pediatric Vision (Corrective Lenses or Frames) | 20% up to $250 per pair of lenses; over $250: 80% |
Adult Vision, Air Ambulance, coverage in the U.S.
| Refraction Exam (Adults) | $15 |
| Adult Vision | 100% reimbursement up to $125 per pair of lenses and frame per year |
| Air Ambulance in Puerto Rico | 30% |
| Emergency Services in the US | 20% Coinsurance |
| Services in the US (not available in PR) | 20% Coinsurance |
Procedure for severe obesity management
| Bariatric Surgery Procedure | FR $150 / PR $0 |
Diagnosis, prevention, and dental treatments
| Dental Benefit | $0–$1,000: coinsurance applies; $1,001+: 80% |
| Diagnostic & Preventive | 0% |
| Minor Restorative | 20% |
| Major Restorative | 50% |
Note: This is a summary of benefits. Consult your plan documents for complete information. Copayments and coinsurance are subject to the annual maximum limit.
Complete the form and we’ll help you choose the best option.
We have received your information and appreciate
your interest in our health plans.
One of our Sales Representatives will be in touch with you to provide personalized guidance
and share details about the plan you are interested in.
Thank you for considering Plan de Salud Menonita as
your health insurance provider.
We have received your information and appreciate
your interest in our health plans.
One of our Sales Representatives will be in touch with you to provide personalized guidance
and share details about the plan you are interested in.
Thank you for considering Plan de Salud Menonita as
your health insurance provider.
Complete the form so we can help you with your questions.
Complete the form and we’ll help you choose the best option.