College Insurance Program
2022-2023 Plan Highlights
Copayment, coinsurance and deductible payments for the services listed below apply to the out-of-pocket maximum for the plan year (effective July 1, 2022 - June 30, 2023).
Enroll Online 2021-2022 Plan Details
2023 Summary of Benefits and Coverage
| Plan Year Deductible | You pay $0 |
| Individual Out-of-Pocket Max | You pay $3,000 |
| Family Out-of-Pocket Max | You pay $6,000 |
Benefits Overview
$ = Copay % = Coinsurance
Medical Benefits
|
Physician Visit A visit with your primary care provider or another provider in your doctor’s office. |
You pay $30 |
|
Specialist A visit with an in-network provider who specializes in a specific area of healthcare. |
You pay $30 |
|
Virtual Visits An on-demand visit with a provider by phone or video. |
You pay $10 |
|
Wellness and Preventive Services Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/frequency schedules apply. |
You pay $0 |
|
Emergency Room Care from an emergency department. |
You pay $200 |
|
Ambulance Transport |
You pay $0 |
|
Urgent Care |
You pay $30 |
|
Diagnostic Testing - X-Rays, Lab Services Preauthorization is required for imaging. |
You pay $0 |
|
Outpatient Surgery Preauthorization may be required for certain procedures. |
You pay $200 |
|
Hospitalization Preauthorization is required. |
You pay $250 |
|
Home Health Care Preauthorization is required. |
You pay $30 |
|
Rehabilitation Services Preauthorization is required, up to 60 visits per condition per plan year. |
You pay $30 |
|
Skilled Nursing Care Preauthorization is required. |
You pay $0 |
|
Durable Medical Equipment Preauthorization may be required for certain medical equipment. |
You pay 20% |
|
Hospice Services |
You pay $0 |
Prescriptions
|
Reduced Generic Tier 1 30-day supply |
You pay
$4 $10 |
|
Generic Tier 1 30-day supply |
You pay
$12 $30 |
|
Preferred Brand 30-day supply |
You pay
$24 $60 |
|
Non-Preferred Brand 30-day supply |
You pay
$48 $120 |
|
Specialty Tier 4 30-day supply |
You pay
$96 N/A |
*Specialty medication is limited to a 30-day supply. This 90-day copay amount applies only to non-specialty medication.
Maternity
|
Prenatal Care Care during pregnancy. |
Per pregnancy $50 |
|
Maternity Inpatient Care received in the hospital for the birth of a baby. |
You pay $250 |
Mental Health
|
Outpatient Mental health, behavioral health or substance abuse services. |
You pay $30 |
|
Inpatient (Prior authorizaion is required.) Mental health, behavioral health or substance abuse services. |
You pay $250 |
Care Coordination
Get help reaching your health goals (like stress management, weight management or preparing for a marathon) and taking control of long-term conditions (like diabetes, high blood pressure or high-risk pregnancy).
Your care coordinator or health coach is there to support you every step of the way, calling you regularly and acting as your go-to person for support with your goals.
Finding Care
With a statewide network of trusted doctors to choose from, you get access to reliable care with lots of options.
- Find doctors and hospitals in network.
- Get 24/7 answers to your health questions with the Nurse Advice Line.
- Schedule a virtual visit from home.
Perks and Programs
Your plan is made with plenty of perks to help you with your health goals. Get access to a fitness benefit, wellness perks and other programs made with you in mind.
Ready to get started?
Call us at (800) 851-3379 (TTY 711), daily from 8 a.m. to 5 p.m. local time. Voicemail is used on holidays and weekends, April 1 to September 30.