Plan Information

The benefits shown below reflect the amount you pay when you see a participating provider (or an in-network provider).

Plan Overview

Annual Cost Estimates

Cost Sharing Overview

Deductibles

The amount of money you pay for covered healthcare services before your insurance company starts to pay. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services, and your insurance company pays the rest

Prescription Drug Deductible

This is the amount you must pay each year for your prescriptions before your healthcare plan begins to pay its share of your covered drugs.

Out-of-Pocket Maximum

The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits.

Prescription Drug Out-of-Pocket Maximum

The most you have to pay for prescription drugs in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of your additional prescription drugs.

Physician Services

Preventive Care

Primary Care Visit

Patient Centered Medical Home (PCMH)

Specialist Visit

A visit with a doctor who is not your primary care doctor. These doctors focus on a specific types of health care. Examples of specialists include obstetricians, surgeons, or cardiologists.

Prescription Drugs - 30 Day Supply from a Retail Pharmacy

Prescription Drugs from a Retail Pharmacy

Formulary Link

Network Information

Urgent and Emergency Care

Hospital Services

Outpatient Services

Mental Health, Substance Abuse & Behavioral Health

Additional Information

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This is a partial summary of benefits and coverage and should not be considered a contract. This information, including all quoted rates, should be used for informational purposes only. Changes may be made to the benefits and coverage policies described here. You should only rely upon the Evidence of Coverage document provided to you from your health insurance company for information on rates, covered benefits, limitations and exclusions.

*An asterisk (*) at the beginning of the plan name indicates that this plan does not cover abortion except in very limited circumstances (check your policy or plan document for further information). No portion of the premium paid for this plan is placed in an allocation account, established for the coverage of elective abortion services, and defined by 45 CFR §156.280 (e)(3).

Insurance companies provide updates to their provider networks to HealthSource RI on a monthly basis. This may impact the accuracy of the information above. Please call or consult the website of your chosen insurance provider for the most up-to-date information regarding in and out-of-network providers.

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Plan Information

The benefits shown below reflect the amount you pay when you see a participating provider (or an in-network provider).

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