Econo

For frequent consultations

Econo is recommended if you visit doctors frequently and want to save

Hospital of your choice

Glasses up to
$150 per year

Life insurance included

Generics with low copay

Summary of Benefits:

Click any category to see detailed copays and coverage.

Benefit / Service Category

Annual Medical Deductible / MOOP

Annual limit on the member’s medical expenses

Individual

$6,350

Couple - Family

$12,700

Regular Hospitalization

Hospital stays and inpatient care

Preferred Network / Out-of-Network

$0 Preferred Network
$150 Out-of-Network

Mental Health Hospitalization

Partial hospitalization and ambulatory surgery

Partial Hospitalization

$150

Ambulatory Surgery

$0 Preferred Network
$70 Out-of-Network

Emergency Room

Immediate emergency care

Accident / Illness

$30 Preferred Network
$50 Out-of-Network

Telehealth Referrals

$0 Preferred Network
Not applicable

Laboratories

0% Preferred Network
30% Out-of-Network

X-Ray

0% Preferred Network
20% Out-of-Network

Diagnostic Tests

40%

Specialized Tests

40%

Sonograms

0% Preferred Network
40% Out-of-Network

MRI and CT Scans

20% Preferred Network
40% Out-of-Network

Endoscopies

40%

Lithotripsy

40%

Medical Visits

Consultations and treatments without hospitalization

Primary Care Physician

$7

Specialist

$15

Sub-specialist

$20

Podiatrist

$15

Psychiatrist

$15

Psychologist

$15

Chiropractor

$15

Ambulatory Therapies

Chemotherapy and physical, respiratory, and chiropractic therapies

Chiropractic Manipulations

$7

Chemotherapy

30%

Physical therapy

$7

Respiratory Therapy

$7

Dental

Diagnosis, prevention, and dental treatments

Maximum Coverage

$500 per Subscriber

Excess Maximum Coverage

Not applicable

Diagnostic and Preventive

0%

Minor Restorative

20%

Major Restorative

Not covered

Orthodontics

Not covered

Pharmacy

Covered prescription medications

Maximum Coverage

$800

Excess Maximum Coverage

90%

Generic Rule

Generic First Option

Generic

$7

Preferred Brand

Not covered

Non-Preferred Brand

Not covered

Specialized Products

Not covered

Chemotherapy

30%

Glasses and Lenses

Coverage of glasses with reimbursement and refraction exam

Covered by Reimbursement
$150 per contract year
Refraction Exam
$15

Note: This is a summary of benefits. Consult your plan documents for complete information. Copayments and coinsurance are subject to the annual maximum limit.

Benefit / Service Category

Annual Medical Deductible / MOOP

Annual limit on the member’s medical expenses

Individual	$6,350
Couple - Family	$12,700

Regular Hospitalization

Hospital stays and inpatient care

Preferred Network / Out-of-Network

Individual	$6,350
Couple - Family	$12,700

Mental Health Hospitalization

Partial hospitalization and ambulatory surgery

Partial Hospitalization	$150
Outpatient Surgery	$0 Preferred Network $70 Out-of-Network

Sala de emergencia

Immediate emergency care

Accident / Illness	$30 Preferred Network $50 Out-of-Network
Telehealth Referrals	$0 Preferred Network Not applicable
Laboratory Services	0% Preferred Network 30% Out-of-Network
X-rays	0% Preferred Network 20% Out-of-Network
Diagnostic Tests	40%
Specialized Tests	40%
Ultrasounds	0% Preferred Network 40% Out-of-Network
MRI and CT Scans	20% Preferred Network 40% Out-of-Network
Endoscopies	40%
Lithotripsy	40%

Visitas Médicas

Consultations and treatments without hospitalization

General Practitioner	$7
Specialist	$15
Subspecialist	$20
Podiatrist	$15
Psychiatrist	$15
Psychologist	$15
Chiropractor	$15

Ambulatory Therapies

Chemotherapy and physical, respiratory, and chiropractic therapies

Chiropractic Manipulations	$7
Chemotherapy	30%
Physical Therapy	$7
Respiratory Therapy	$7

Dental

Diagnosis, prevention, and dental treatments

Coverage Maximum	$500 per Subscriber
Maximum Coverage Excess	Not applicable
Diagnostic and Preventive	0%
Minor Restorative	20%
Major Restorative	Not covered
Orthodontics	Not covered

Pharmacy

Covered prescription medications

Maximum Coverage	$800
Maximum Coverage Excess	90%
Generic Rule	Generic First Option
Generic	$7
Preferred Brand	Not covered
Non-Preferred Brand	Not covered
Specialty Drugs	Not covered
Chemotherapy	30%

Glasses and Lenses

Coverage of glasses with reimbursement and refraction exam

Covered by Reimbursement
$150 per contract year
Refraction Exam
$15

Note: This is a summary of benefits. Consult your plan documents for complete information. Copayments and coinsurance are subject to the annual maximum limit.

Econo

Summary of Benefits:

Benefit / Service Category

Individual

$6,350

Couple - Family

$12,700

$0 Preferred Network$150 Out-of-Network

Partial Hospitalization

$150

Ambulatory Surgery

$0 Preferred Network$70 Out-of-Network

Accident / Illness

$30 Preferred Network$50 Out-of-Network

Telehealth Referrals

$0 Preferred NetworkNot applicable

Laboratories

0% Preferred Network30% Out-of-Network

X-Ray

0% Preferred Network20% Out-of-Network

Diagnostic Tests

40%

Specialized Tests

40%

Sonograms

0% Preferred Network40% Out-of-Network

MRI and CT Scans

20% Preferred Network40% Out-of-Network

Endoscopies

40%

Lithotripsy

40%

Primary Care Physician

$7

Specialist

$15

Sub-specialist

$20

Podiatrist

$15

Psychiatrist

$15

Psychologist

$15

Chiropractor

$15

Chiropractic Manipulations

$7

Chemotherapy

30%

Physical therapy

$7

Respiratory Therapy

$7

Maximum Coverage

$500 per Subscriber

Excess Maximum Coverage

Not applicable

Diagnostic and Preventive

0%

Minor Restorative

20%

Major Restorative

Not covered

Orthodontics

Not covered

Maximum Coverage

$800

Excess Maximum Coverage

90%

Generic Rule

Generic First Option

Generic

$7

Preferred Brand

Not covered​

Non-Preferred Brand

Not covered​

Specialized Products

Not covered​

$0 Preferred Network
$150 Out-of-Network

$0 Preferred Network
$70 Out-of-Network

$30 Preferred Network
$50 Out-of-Network

$0 Preferred Network
Not applicable

0% Preferred Network
30% Out-of-Network

0% Preferred Network
20% Out-of-Network

0% Preferred Network
40% Out-of-Network

20% Preferred Network
40% Out-of-Network

Not covered

Not covered

Not covered

Covered by Reimbursement
$150 per contract year
Refraction Exam
$15