Health insurance coverage from a name you trust You can feel confident knowing that Indiana University Health Plans is an insurance provider that’s part of Indiana University Health, so IU Health Plans is uniquely positioned to offer you the highest quality care at an incredible value.
WITH IU HEALTH PLANS, YOU GET: n
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Coverage from a name you know and trust Access to primary care physicians, specialists and hospitals of IU Health, including Riley Hospital for Children at Indiana University Health, one of the nation’s top children’s hospitals Access to other providers and hospitals throughout Indiana that are close to home, including Deaconess Health System
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Free yearly check-ups, screenings and vaccines
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Affordable doctor office visits
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Prescription drugs at low cost to you, including $0 preventive care drugs
iuhealthplans.org
855.413.2432
To request information or get assistance in Spanish or another language, please call IU Health Plans at 855.413.2432. IU Health Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. IU Health Plans cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. IU Health Plans 遵守適用的聯邦民權法律規定，不因種族、膚色、民族血統、年齡、殘障或性。 ATTENTION: Our Member Services department has free language interpreter services available for non-English speakers. Call 855.413.2432. (TTY: 800.743.3333). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 855.413.2432 (TTY: 800.743.3333). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 855.413.2432 (TTY: 800.743.3333). IUHEXG_146
IU Health Plans Silver Prime IU Health Plans In-Network Benefit: IU Health Plans covers healthcare services for physicians and hospitals that are in-network only. You can see our directory of covered physicians and hospitals at iuhealthplans.org/individual. If you have a true emergency, your care is covered at any hospital. A true emergency is when you have a serious medical condition that could cause lasting harm or loss of life if you do not seek care immediately, such as a vehicle accident, difficulty breathing or severe bleeding. See the key health insurance and medical terms in this packet for helpful explanations of some of the words and terms in this chart. Plan Benefits
Your Cost (In-network providers only)
Deductible (Individual/Family)
$4,500/$9,000
Out-of-Pocket Maximum (Individual/Family)
$7,150/$14,300
Coinsurance
20% after deductible
Emergency and Urgent Care Services Emergency Room Visit
20% after deductible
Urgent Care Center Services
$100 copay
Provider Services Primary Care Office Visit
$15 copay
Specialist Care Office Visit
$30 copay
Behavioral Health Professional Visit
$15 copay
Preventive Care (e.g., yearly check-ups, screenings and vaccines)
FREE
X-rays and Diagnostic Imaging
20% after deductible
Imaging (e.g., CT/PET Scans and MRIs)
20% after deductible
Inpatient and Outpatient Services Inpatient Hospital
20% after deductible
Laboratory Outpatient and Professional Services
20% after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
20% after deductible
Outpatient Surgery Physician/Surgical Services
20% after deductible
Other Medical Services Mental/Behavioral Health and Substance Abuse Disorder Outpatient Services
$15 copay
Rehabilitative Speech Therapy
20% after deductible
Rehabilitative Occupational/Physical Therapy
20% after deductible
Skilled Nursing Facility
20% after deductible
Pediatric Vision Services Pediatric Vision
$0 yearly routine exam $0 eyeglasses (1 set of frames and lenses per year) $0 contact lenses (in lieu of eyeglasses)
Prescription Drug Coverage Tier 1 (Preferred Generic)
$5 copay
Tier 2 (Non-Preferred Generic)
$15 copay
Tier 3 (Preferred Brand)
20% after deductible
Tier 4 (Non-Preferred Brand)
20% after deductible
Tier 5 (Specialty)
20% after deductible
Tier 6 (ACA Zero Cost Preventive Care)
$0
The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact us at
855.413.2432.
IUHEXG_146 © 2016 IUHealth 9/16 Member
Key health insurance and medical definitions Network: The facilities, providers and suppliers your health insurer or plan has contracted with to provide healthcare services.
Deductible: The amount you owe for healthcare services your health insurance or plan covers before your health insurance or plan begins to pay.
Out-of-pocket (OOP) costs: Your expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance and copayments for covered services plus all costs for services that aren't covered.
Copayment: A fixed amount you pay for a covered healthcare service, usually at the time when you get the service. Amounts vary by plans and services.
Coinsurance: Your share of the costs of a covered healthcare service, calculated as a percentage of the allowed amount by your plan. You pay coinsurance plus any deductibles you owe.
Essential health benefits: Comprehensive care that covers all your healthcare needs, including emergency services, mental health services and prescription drug coverage.
Preventive care: Preventive services that can help you avoid illness and improve your health, including yearly check-ups, vaccines and screenings.
Health Savings Account (HSA): HSA plans allow you to contribute funds to a personal savings account on a pre-tax basis, which can be used to pay for eligible medical expenses until your deductible is met.
iuhealthplans.org
855.413.2432
IU Health Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. IU Health Plans cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. IU Health Plans 遵守適用的聯邦民權法律規定，不因種族、膚色、民族血統、年齡、殘障或性。 ATTENTION: Our Member Services department has free language interpreter services available for non-English speakers. Call 855.413.2432. (TTY: 800.743.3333). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 855.413.2432 (TTY: 800.743.3333). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 855.413.2432 (TTY: 800.743.3333).
IUHEXG_146 © 2016 IUHealth 9/16 Member
