Your Medical Benefits
LocalPlus Plan - LocalPlus Bronze Plan
Benefit Summary
Group # 00609940
The LocalPlus® plan includes a local limited network and gives you cost-efficient access to quality doctors, specialists and hospitals – right where you live.
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Plan Documents
| In-Network | Out-of-Network | |
|---|---|---|
| Plan Name | LocalPlus Plan - LocalPlus Bronze Plan | |
| Plan Coinsurance | Plan pays 80% | Plan pays 50% |
| Individual Deductible | Individual: $5,000 | Individual: $10,000 |
| Family Deductible | Family: $10,000 | Family: $20,000 |
| Individual Out-of-Pocket | Individual: $7,000 | Individual: $14,000 |
| Family Out-of-Pocket | Family: $14,000 | Family: $28,000 |
| Primary Care Office Visit | $25 copay, and plan pays 100% | Plan pays 50% |
| Specialist Care Office Visit | $75 copay, and plan pays 100% | Plan pays 50% |
| Emergency Room | $300 copay, and plan pays 80% | |
| Urgent Care | $50 copay, and plan pays 100% | Plan pays 50% |
| Outpatient Radiology | Plan pays 80% | Plan pays 50% |
| Independent Laboratory | Plan pays 80% | Plan pays 50% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | Plan pays 80% | Plan pays 50% |
| Pharmacy Formulary | Advantage | |
| Retail Pharmacy Customer Share | Retail (per 30-day supply): Generic: You pay $25 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $75 Specialty: You pay $250 Retail (per 90-day supply): Generic: You pay $63 Preferred Brand: You pay $125 Non-Preferred Brand: You pay $188 | Not Covered for all benefits |
| Home Delivery Pharmacy Customer Share | Home Delivery (per 90-day supply): Generic: You pay $63 Preferred Brand: You pay $125 Non-Preferred Brand: You pay $188 Home Delivery (per 30-day supply): Specialty: You pay $250 | Not Covered for all benefits |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.
Benefit Summary
Group # 00609940
The LocalPlus® plan includes a local limited network and gives you cost-efficient access to quality doctors, specialists and hospitals – right where you live.
Plan Documents
| In-Network | Out-of-Network | |
|---|---|---|
| Plan Name | LocalPlus Plan - LocalPlus Bronze Plan | |
| Plan Coinsurance | Plan pays 80% | Plan pays 50% |
| Individual Deductible | Individual: $5,000 | Individual: $10,000 |
| Family Deductible | Family: $10,000 | Family: $20,000 |
| Individual Out-of-Pocket | Individual: $7,000 | Individual: $14,000 |
| Family Out-of-Pocket | Family: $14,000 | Family: $28,000 |
| Primary Care Office Visit | $25 copay, and plan pays 100% | Plan pays 50% |
| Specialist Care Office Visit | $75 copay, and plan pays 100% | Plan pays 50% |
| Emergency Room | $300 copay, and plan pays 80% | |
| Urgent Care | $50 copay, and plan pays 100% | Plan pays 50% |
| Outpatient Radiology | Plan pays 80% | Plan pays 50% |
| Independent Laboratory | Plan pays 80% | Plan pays 50% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | Plan pays 80% | Plan pays 50% |
| Pharmacy Formulary | Advantage | |
| Retail Pharmacy Customer Share | Retail (per 30-day supply): Generic: You pay $25 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $75 Specialty: You pay $250 Retail (per 90-day supply): Generic: You pay $63 Preferred Brand: You pay $125 Non-Preferred Brand: You pay $188 | Not Covered for all benefits |
| Home Delivery Pharmacy Customer Share | Home Delivery (per 90-day supply): Generic: You pay $63 Preferred Brand: You pay $125 Non-Preferred Brand: You pay $188 Home Delivery (per 30-day supply): Specialty: You pay $250 | Not Covered for all benefits |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.