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 Preferred Network,
$150 Out-of-Network
In-office diagnostic / surgical procedures
20% Preferred Network,
50% Out-of-Network
Endoscopic procedures
20% Preferred Network,
50% Out-of-Network
Laboratory and X-Ray Services
Diagnostic tests and medical studies
Laboratory
20% Preferred Network,
50% Out-of-Network
X-Ray
20% Preferred Network,
50% Out-of-Network
PET Scan, CT Scan, MRI, or PET CT (1 per year)
20% Preferred Network,
50% Out-of-Network
Hospitalization
Hospital stays and inpatient care
Partial (including Mental Health)
$30 Preferred Network,
$100 Out-of-Network
Complete with Pre-authorization
including Mental Health
$50 Preferred Network,
$200 Out-of-Network
Complete without Pre-authorization
including Mental Health
$50 Preferred Network,
$200 Out-of-Network
Diestra Nursing Facilities
or "Skilled Nursing"
$50 Preferred & Out-of-Network
Surgical assistant
20% Preferred,
80% Out-of-Network
Rehabilitation and Medical Equipment
Therapies and necessary medical equipment
Physical therapy
$10 Preferred and Out-of-Network
Respiratory therapy
$10 Preferred and Out-of-Network
Home health care
20% Preferred,
50% Out-of-Network
Durable medical equipment
30% up to $5,000, Excess 80%
Chiropractic Manipulations
$10 In-Network and Out-of-Network
Mental Health
Group therapy and emotional support
Group therapy
$10 In-Network
and Out-of-Network
Collateral visits
$10 In-Network
and Out-of-Network
Pharmacy
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 Drugs
50% for
$0-$1,000, $1,001+ 60%
Over-the-Counter (OTC) medications
Not covered
Prevention, Wellness, and Chronic Conditions
Preventive care and ongoing management
Preventive Services
0% Preferred Network and Out-of-Network
Preventive vaccines
0% Preferred Network and Out-of-Network
Respiratory Syncytial Virus vaccine
20% Preferred Network and Out-of-Network
Pediatric Vision Services
Exams, lenses, and vision benefits
Eye Exam (Refraction)
$0 Preferred Network and Out-of-Network
Pediatric Vision (Corrective Lenses or Frames)
20% up to $250 per glasses; over $250: 80%
Other Services
Adult Vision, Air Ambulance, coverage in the U.S.
Refraction Exam (Adults)
$10 Preferred Network
and Out-of-Network
Adult Vision
100% reimbursement
up to $125 per pair of lenses and frame per year
Air ambulance in Puerto Rico
$20 Preferred Network
and Out-of-Network
Emergency services in the U.S.
20% coinsurance
Services in the U.S. (not available in PR)
20% coinsurance
Bariatric Surgery for Morbid Obesity
Procedure for severe obesity management
Bariatric surgery procedure
$50 Preferred Network,
$200 Out-of-Network
Dental Coverage
Diagnosis, prevention, and dental treatments
Dental Benefit
$0–$1,000: coinsurance applies
$1,001+: 60%
Diagnostic & Preventive
$0 Preferred Network
and Out-of-Network
Minor Restorative
$20 Preferred Network
and Out-of-Network
Major Restorative
$50 Preferred Network
and Out-of-Network
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
Combined MOOP (medical and prescriptions)
Total maximum out-of-pocket expenses per year
Individual
$3,500 Preferred and Out-of-Network
Family
$7,000 Preferred and Out-of-Network
Emergency Services
Immediate emergency care
Accident
$25 Preferred, $75 Out-of-Network
Illness
$25 Preferred, $75 Out-of-Network
Outpatient Services
Consultations and treatments without hospitalization
Primary Care Physician
$5
Specialist
$10
Sub-Specialist
$15
Psychiatrist
$10
Psychologist
$10
Podiatry
$10
Chiropractor
$10
Audiologist
$10
Optometrist
$10
Nutritionist
Reimbursement up to $20 per visit, 4 per year
Ambulatory Surgery Center
$50 Preferred, $150 Out-of-Network
In-office Diagnostic / Surgical Procedures
20% Preferred, 50% Out-of-Network
Endoscopic Procedures
20% Preferred, 50% Out-of-Network
Laboratory and X-Ray Services
Diagnostic tests and medical studies
Laboratory
20% Preferred, 50% Out-of-Network
X-Ray
20% Preferred, 50% Out-of-Network
PET Scan, CT Scan, MRI, or PET CT (1 year)
20% Preferred, 50% Out-of-Network
Hospitalization
Hospital stays and inpatient care
Partial including Mental Health
$30 Preferred, $100 Out-of-Network
Complete with Preauthorization including Mental Health
$50 Preferred, $200 Out-of-Network
Complete without Preauthorization including Mental Health
$50 Preferred, $200 Out-of-Network
Skilled Nursing Facilities
$50 Preferred and Out-of-Network
Surgical Assistance
20% Preferred, 80% Out-of-Network
Rehabilitation and Medical Equipment
Therapies and necessary medical equipment
Physical Therapy
$10 Preferred and Out-of-Network
Respiratory Therapy
$10 Preferred and Out-of-Network
Home Health Care
20% Preferred, 50% Out-of-Network
Durable Medical Equipment
30% up to $5,000, Excess 80%
Chiropractic Manipulations
$10 Preferred and Out-of-Network
Mental Health
Group therapy and emotional support
Group Therapy
$10 Preferred and Out-of-Network
Collateral Visits
$10 Preferred and Out-of-Network
Pharmacy
Covered prescription medications
Pharmacy Benefit
$0-$1,000: applicable copays and coinsurance; $1,001+: 60% coinsurance
Bioequivalent Generic
$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
Prevention, Wellness, and Chronic Conditions
Preventive care and ongoing management
Preventive Services
0% Preferred and Out-of-Network
Preventive Vaccinations
0% Preferred and Out-of-Network
Respiratory Syncytial Virus (RSV) Vaccine
20% Preferred and Out-of-Network
Pediatric Vision Services
Exams, lenses, and vision benefits
Vision Exam (Refraction)
$0 Preferred and Out-of-Network
Pediatric Vision (Corrective Lenses or Frames)
20% up to $250 per lenses; over $250: 80%
Other Services
Adult Vision, Air Ambulance, coverage in the U.S.
Adult Vision Exam (Refraction)
$10 Preferred and Out-of-Network
Adult Vision
100% reimbursement up to $125 for one pair of lenses and frame per year
Air Ambulance in Puerto Rico
$20 Preferred and Out-of-Network
Emergency Services in the US
20% Coinsurance
Services in the US (not available in PR)
20% Coinsurance
Bariatric Surgery for Morbid Obesity
Procedure for severe obesity management
Bariatric Surgery Procedure
$50 Preferred, $200 Out-of-Network
Dental Coverage
Diagnosis, prevention, and dental treatments
Dental Benefit
$0-$1,000: Coinsurance; $1,001+: 60%
Diagnostic & Preventive
$0 Preferred and Out-of-Network
Minor Restorative
$20 Preferred and Out-of-Network
Major Restorative
$50 Preferred and Out-of-Network
Note: This is a summary of benefits. Consult your plan documents for complete information. Copayments and coinsurance are subject to the annual maximum limit.
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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.