The Platinum Plan provides strong coverage, affordable copays, and full access to
our provider network.
Low and predictable copays
Protección contra gastos escesivos
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
Note: This is a summary of benefits. Consult your plan documents for complete information. Copayments and coinsurance are subject to the annual maximum limit.
Total maximum out-of-pocket expenses per year
| Individual | $3,500 |
| Family | $7,000 |
Immediate emergency care
| Accident | $25 |
| Illness | $25 |
Consultations and treatments without hospitalization
| Primary Care Physician | $5 |
| Specialist | $10 |
| Sub-Specialist | $15 |
| Psychiatrist | $10 |
| Psychologist | $10 |
| Podiatrist | $10 |
| Chiropractor | $10 |
| Audiologist | $10 |
| Optometrist | $10 |
| Nutritionist | Reimbursement up to $20 per visit, 4 per year |
| Ambulatory Surgery Center | $50 |
| Office Diagnostics / Surgical Procedures | 20% |
| Endoscopic Procedures | 20% |
Diagnostic tests and medical studies
| Laboratory | 20% |
| X-Ray | 20% |
| PET Scan, CT Scan, MRI, or PET CT (1 year) | 20% |
Hospital stays and inpatient care
| Partial, including Mental Health | $30 |
| Full with Pre-authorization, including Mental Health | $50 |
| Full without Pre-authorization, including Mental Health | $50 |
| Skilled Nursing Facilities | $50 |
| Surgical Assistance | Subscriber pays 20% |
Therapies and necessary medical equipment
| Physical Therapy | $10 |
| Respiratory Therapy | $10 |
| Home Health Care | 20% |
| Durable Medical Equipment | 20% up to $5,000, excess 80% |
| Chiropractic Manipulations | $10 |
Group therapy and emotional support
| Group Therapy | $10 |
| Collateral Visits | $10 |
Covered prescription medications
| Pharmacy Benefit | $0–$1,000: applicable copays and coinsurance; $1,001+: 60% coinsurance |
| Generic Bioequivalent | $5 for $0–$1,000; $1,001+: 60% |
| Preferred Brand | 20% (min $20) for $0–$1,000; $1,001+: 60% |
| Non-Preferred Brand | 30% (min $30) for $0–$1,000; $1,001+: 60% |
| Specialty Products | 50% for $0–$1,000; $1,001+: 60% |
| Over-the-Counter (OTC) Medications | Not Covered |
Preventive care and ongoing management
| Preventive Services | 0% |
| Preventive Vaccinations | 0% |
| Respiratory Syncytial Virus (RSV) Vaccine | 20% |
Exams, lenses, and vision benefits
| Eye Exam (Refraction) | $0 |
| Pediatric Vision | 20% up to $250 per lenses; over $250: 80% |
Adult Vision, Air Ambulance, coverage in the U.S.
| Refraction Exam (Adults) | $10 |
| Adult Vision | 100% reimbursement up to $125 for one pair of lenses and frames per year |
| Air Ambulance in Puerto Rico | 20% |
| Emergency Services in the U.S. | 20% coinsurance |
| Services in the U.S. (not available in PR) | 20% coinsurance |
Procedure for severe obesity management
| Bariatric Surgery Procedure | $50 |
Diagnosis, prevention, and dental treatments
| Dental Benefit | $0–$1,000: coinsurance applies; $1,001+: 60% |
| 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.