TLC Plan Comparison

THE LOCAL CHOICE PLANS COMPARISON FOR 2019- 2020
  KEY ADVANTAGE 250 KEY ADVANTAGE 1000 HIGH DEDUCTIBLE HEALTH PLAN
PLAN YEAR DEDUCTIBLE SINGLE DUAL FAMILY SINGLE DUAL FAMILY SINGLE DUAL FAMILY
     IN NETWORK $250 $500 $500 $1,000 $2,000 $2,000 $2,800 $5,600 $5,600
     OUT-OF-NETWORK $500 $1,000 $1,000 $2,000 $4,000 $4,000 Combined for In-Network and Out-of-Network services.
PLAN YEAR OUT-OF-POCKET EXPENSE LIMIT                  
     IN NETWORK $3,000 $6,000 $6,000 $5,000 $10,000 $10,000 $5,000 $10,000 $10,000
     OUT-OF-NETWORK $5,000 $10,000 $10,000 $9,000 $18,000 $18,000 $10,000 $20,000 $20,000
OUT-OF-NETWORK BENEFITS Yes. Once you meet the out-of-network deductible you pay 30% Yes. Once you meet the out-of-network deductible you pay 30% Yes. Once you meet the combined deductible you pay 40% 
  coinsurance for medical and behavioral health services.  coinsurance for medical and behavioral health services.  coinsurance for medical, behavioral health, and prescription drug 
  Copayments do not apply to medical and behavioral health Copayments do not apply to medical and behavioral health services from out-of-network providers.  
  services. Copayments and coinsurance for routine vision, services. Copayments and coinsurance for routine vision,    
  outpatient prescription drugs, and dental services still apply. outpatient prescription drugs, and dental services still apply.    
MEDICAL CARE WHEN TRAVELING INCLUDED INCLUDED INCLUDED
LIFETIME MAXIMUM UNLIMITED UNLIMITED UNLIMITED
COVERED SERVICES IN-NETWORK YOU PAY IN-NETWORK YOU PAY IN-NETWORK YOU PAY
AMBULANCE TRAVEL 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE
AUTISM SPECTRUM DISORDER (2 YEARS TO 10 YEARS) COPAYMENT/COINSURANCE DETERMINED BY SERVICE RECEIVED COPAYMENT/COINSURANCE DETERMINED BY SERVICE RECEIVED 20% COINSURANCE AFTER DEDUCTIBLE
BEHAVIORAL HEALTH AND EAP                  
INPATIENT TREATMENT                  
     FACILITY SERVICES $400 COPAYMENT PER STAY 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE
     PROFESSIONAL PROVIDER SERVICES $0 $0 20% COINSURANCE AFTER DEDUCTIBLE
OUTPATIENT TREATMENT                  
     PROFESSIONAL PROVIDER SERVICES $20 COPAYMENT $25 COPAYMENT 20% COINSURANCE AFTER DEDUCTIBLE
EMPLOYEE ASSISTANCE PROGRAM (EAP)                  
     4 VISITS PER ISSUE (PER PLAN YEAR) $0 $0 $0
DENTAL CARE SINGLE DUAL FAMILY SINGLE DUAL FAMILY SINGLE DUAL FAMILY
PREVENTIVE DENTAL OPTION (DIAGNOSTIC AND PREVENTIVE SERVICES                  
ONLY FOR LOWER PREMIUM) $0 $0 $0 $0 $0 $0 $0 $0 $0
COMPREHENSIVE DENTAL OPTION (FOR HIGHER PREMIUM)                  
     DENTAL PLAN YEAR DEDUCTIBLE $25 $50 $75 $25 $50 $75 $25 $50 $75
     PLAN YEAR MAXIMUM (EXCEPT ORTHODONTICS) $1,500 $1,500 $1,500
     PREVENTIVE DENTAL CARE $0 $0 $0
     PRIMARY DENTAL CARE 20% COINSURANCE AFTER DENTAL DEDUCTIBLE 20% COINSURANCE AFTER DENTAL DEDUCTIBLE 20% COINSURANCE AFTER DENTAL DEDUCTIBLE
     MAJOR DENTAL CARE 50% COINSURANCE AFTER DENTAL DEDUCTIBLE 50% COINSURANCE AFTER DENTAL DEDUCTIBLE 50% COINSURANCE AFTER DENTAL DEDUCTIBLE
     ORTHODONTIC SERVICES (INCLUDES ADULT ORTHO) 50% COINSURANCE, NO DENTAL DEDUCTIBLE, WITH $1,500 LIFETIME 50% COINSURANCE, NO DENTAL DEDUCTIBLE, WITH $1,500 LIFETIME 50% COINSURANCE, NO DENTAL DEDUCTIBLE, WITH $1,500 LIFETIME
  MAXIMUM MAXIMUM MAXIMUM
DIABETIC EDUCATION $0 $0 20% COINSURANCE AFTER DEDUCTIBLE
DIABETIC EQUIPMENT 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE
DIABETIC SUPPLIES - SEE OUTPATIENT PRESCRIPTION DRUGS      
DIAGNOSTIC TESTS AND X-RAYS                  
(FOR SPECIFIC CONDITIONS OR DISEASES AT A DOCTOR'S OFFICE, 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE
EMERGENCY ROOM OR OUTPATIENT HOSPITAL DEPARTMENT)
DOCTOR VISITS - ON AN OUTPATIENT BASIS                  
     PRIMARY CARE PHYSICIANS $20 COPAYMENT $25 COPAYMENT 20% COINSURANCE AFTER DEDUCTIBLE
     SPECIALTY CARE PROVIDERS $35 COPAYMENT $40 COPAYMENT 20% COINSURANCE AFTER DEDUCTIBLE
EARLY INTERVENTION SERVICES COPAYMENT/COINSURANCE DETERMINED BY SERVICE RECEIVED COPAYMENT/COINSURANCE DETERMINED BY SERVICE RECEIVED 20% COINSURANCE AFTER DEDUCTIBLE
EMERGENCY ROOM VISITS                  
FACILITY SERVICES $350 COPAYMENT PER VISIT 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE
  (WAIVED IF ADMITTED TO HOSPITAL)
PROFESSIONAL PROVIDER SERVICES                  
     PRIMARY CARE PHYSICIANS $20 COPAYMENT $25 COPAYMENT 20% COINSURANCE AFTER DEDUCTIBLE
     SPECIALTY CARE PROVIDERS $35 COPAYMENT $40 COPAYMENT 20% COINSURANCE AFTER DEDUCTIBLE
DIAGNOSTIC TESTS AND X-RAYS 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE
HOME HEALTH SERVICES $0 $0 20% COINSURANCE AFTER DEDUCTIBLE
(90 VISIT PLAN YEAR LIMIT PER MEMBER)
HOME PRIVATE DUTY NURSE'S SERVICES 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE
HOSPICE CARE SERVICES $0 $0 20% COINSURANCE AFTER DEDUCTIBLE
HOSPITAL SERVICES                  
INPATIENT TREATMENT      
     FACILITY SERVICES $400 COPAYMENT PER STAY 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE
     PROFESSIONAL PROVIDER SERVICES          
     * PRIMARY CARE PHYSICIANS $0 $0 20% COINSURANCE AFTER DEDUCTIBLE
     *SPECIALTY CARE PROVIDERS $0 $0 20% COINSURANCE AFTER DEDUCTIBLE
OUTPATIENT TREATMENT                  
     FACILITY SERVICES $150 COPAYMENT 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE
     PROFESSIONAL PROVIDER SERVICES                  
     *PRIMARY CARE PHYSICIANS $20 COPAYMENT $25 COPAYMENT 20% COINSURANCE AFTER DEDUCTIBLE
     *SPECIALTY CARE PROVIDERS $35 COPAYMENT $40 COPAYMENT 20% COINSURANCE AFTER DEDUCTIBLE
DIAGNOSTIC TESTS AND X-RAYS 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE
LIVEHEALTH ONLINE (ONLINE DOCTOR'S VISITS) $20 $25 DETERMINED BY SERVICES RECEIVED
MATERNITY                  
PROFESSIONAL PROVIDER SERVISES (PRENATAL & POSTNATAL CARE)                  
     PRIMARY CARE PHYSICIANS $20 COPAYMENT $25 COPAYMENT 20% COINSURANCE AFTER DEDUCTIBLE
     SPECIALTY CARE PROVIDERS $35 COPAYMENT $40 COPAYMENT 20% COINSURANCE AFTER DEDUCTIBLE
  If your doctor submits one bill for delivery, prenatal, and  If your doctor submits one bill for delivery, prenatal, and   
  postnatal services, there is no copayment required for physician  postnatal services, there is no copayment required for physician   
  care. If your doctor bills separately, your payment responsibility care. If your doctor bills separately, your payment responsibility  
  will be determined by the services received. will be determined by the services received.  
DELIVERY          
     PRIMARY CARE PHYSICIANS $0 $0 20% COINSURANCE AFTER DEDUCTIBLE
     SPECIALTY CARE PROVIDERS $0 $0 20% COINSURANCE AFTER DEDUCTIBLE
HOSPITAL SERVICES FOR DELIVERY $400 COPAYMENT PER STAY* 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE
(DELIVERY ROOM, ANESTHESIA, ROUTINE NURSING CARE FOR NEWBORN)
OUTPATIENT DIAGNOSTIC TESTS 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE
MEDICAL EQUIPMENT, APPLIANCES, FORMULAS, PROSTHETICS & SUPPLIES                  
  20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE
OUTPATIENT PRESCRIPTION DRUGS-MANDATORY GENERIC          
RETAIL UP TO 34-DAY SUPPLY*                  
     *YOU MAY PURCHASE UP TO A 90-DAY SUPPLY AT A RETAIL             TIER 1 $10 COPAYMENT $10 COPAYMENT 20% COINSURANCE AFTER DEDUCTIBLE
 PHARMACY BY PAYING MULTIPLE COPAYMENTS, OR THE                TIER 2 $30 COPAYMENT $30 COPAYMENT
COINSURANCE AFTER THE DEDUCTIBLE                                             TIER 3 $45 COPAYMENT $45 COPAYMENT
TIER 4 $55 COPAYMENT $55 COPAYMENT
HOME DELIVERY SERVICES (MAIL ORDER) - 90 DAY SUPPLY      
                                      TIER 1 $20 COPAYMENT $20 COPAYMENT 20% COINSURANCE AFTER DEDUCTIBLE
TIER 2 $60 COPAYMENT $60 COPAYMENT
TIER 3 $90 COPAYMENT $90 COPAYMENT
TIER 4 $110 COPAYMENT $110 COPAYMENT
DIABETIC SUPPLIES 20% COINSURANCE, NO DEDUCTIBLE 20% COINSURANCE, NO DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE
ROUTINE VISION - BLUE VIEW VISION NETWORK                  
(ONCE EVERY PLAN YEAR)                  
ROUTINE EYE EXAM $35 COPAYMENT $40 COPAYMENT $15 COPAYMENT
EYEGLASS LENSES $20 COPAYMENT $20 COPAYMENT $20 COPAYMENT
EYEGLASS FRAMES UP TO $100 RETAIL ALLOWANCE UP TO $100 RETAIL ALLOWANCE UP TO $100 RETAIL ALLOWANCE
CONTACT LENSES (IN LIEU OF EYEGLASS LENSES)      
     *ELECTIVE UP TO $100 RETAIL ALLOWANCE UP TO $100 RETAIL ALLOWANCE UP TO $100 RETAIL ALLOWANCE
     *NON-ELECTIVE UP TO $250 RETAIL ALLOWANCE UP TO $250 RETAIL ALLOWANCE UP TO $250 RETAIL ALLOWANCE
     *UV COATING, TINTS, STANDARD SCRATCH RESISTANT $15 $15 $15
     *STANDARD POLYCARBONATE $40 $40 $40
     *STANDARD PROGRESSIVE $65 $65 $65
     *STANDARD ANTI-REFLECTIVE $45 $45 $45
     *OTHER ADD-ONS 20% OFF RETAIL 20% OFF RETAIL 20% OFF RETAIL
SHOTS-ALLERGY & THERAPEUTIC INJECTIONS 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE
(AT DOCTOR'S OFFICE, EMERGENCY ROOM OR OUTPATIENT DEPARTMENT)
SKILLED NURSING FACILITY STAYS          
(180-DAY PER STAY LIMITY PER MEMBER)          
     FACILITY SERVICES $0 $0 20% COINSURANCE AFTER DEDUCTIBLE
     PROFESSIONAL PROVIDER SERVICES $0 $0 20% COINSURANCE AFTER DEDUCTIBLE
SPINAL MANIPULATIONS AND OTHER MANUAL MEDICAL INTERVENTIONS                  
(30 VISITS PER PLAN YEAR LIMIT PER MEMBER)      
     PRIMARY CARE PHYSICIANS $20 $25 20% COINSURANCE AFTER DEDUCTIBLE
     SPECIALTY CARE PROVIDERS $35 $40 20% COINSURANCE AFTER DEDUCTIBLE
SURGERY - SEE HOSPITAL SERVICES      
THERAPY SERVICES                  
(INFUSION SERVICES, CARDIAC REHABILITATION THERAPY, CHEMOTHERAPY, RADIATION        
RADIATION THERAPY, RESPIRATORY THERAPY, OCCUPATIONAL THERAPY,       
PHYSICAL THERAPY, AND SPEECH THERAPY)      
FACILITY SERVICES 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE
PROFESSIONAL PROVIDER SERVICES      
     *PRIMARY CARE PHYSCIANS 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE
     *SPECIALTY CARE PROVIDERS 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE 20% COINSURANCE AFTER DEDUCTIBLE
WELLNESS SERVICES                  
WELL CHILD (OFFICE VISITS AT SPECIFIED INTERVALS THROUGH AGE 6) NO COPAYMENT, COINSURANCE, OR DEDUCTIBLE NO COPAYMENT, COINSURANCE, OR DEDUCTIBLE NO COPAYMENT, COINSURANCE, OR DEDUCTIBLE
     PRIMARY CARE PHYSCIANS    
     SPECIALTY CARE PROVIDERS      
     IMMUNIZATIONS AND SCREENING TESTS    
ROUTINE WELLNESS (AGE 7 AND OLDER) NO COPAYMENT, COINSURANCE, OR DEDUCTIBLE NO COPAYMENT, COINSURANCE, OR DEDUCTIBLE NO COPAYMENT, COINSURANCE, OR DEDUCTIBLE
     ANNUAL CHECK-UP VISIT (ONE PER PLAN YEAR)    
     *PRIMARY CARE PHYSCIANS    
     *SPECIALTY CARE PROVIDERS      
     *IMMUNIZATIONS, LAB AND X-RAY SERVICES    
     ROUTINE SCREENINGS, IMMUNIZATIONS, LAB AND X-RAY SERVICES    
     (OUTSIDE OF ANNUAL CHECK-UP VISITS)    
PREVENTIVE CARE (ONE OF EACH PER PLAN YEAR) NO COPAYMENT, COINSURANCE, OR DEDUCTIBLE NO COPAYMENT, COINSURANCE, OR DEDUCTIBLE NO COPAYMENT, COINSURANCE, OR DEDUCTIBLE
     GYNECOLOGICAL EXAM      
     PAP TEST    
     MAMMOGRAPHY SCREENING      
     PROSTATE EXAM (DIGITAL RECTAL EXAM)      
     PROSTATE SPECIFIC ANTIGEN TEST      
     COLORECTAL CANCER SCREENING      
NOTES
1.  This plan comparison document is solely for the purpose of making side-by-side comparisons. Consult the specific plan documents for more detail regarding each individual plan.