Ascension Personalized Care Balanced Silver

35755IN0080005
Silver
EPO

Ascension Personalized Care Balanced Silver is a Silver EPO plan by US HEALTH AND LIFE INSURANCE COMPANY.

IMPORTANT: You are viewing the 2023 version of Ascension Personalized Care Balanced Silver 35755IN0080005. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Ascension Personalized Care Balanced Silver is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Ascension Personalized Care Balanced Silver 35755IN0080005.
Insurer: US HEALTH AND LIFE INSURANCE COMPANY
Network Type: EPO
Metal Type: Silver
HSA Eligible?: Yes
Plan ID: 35755IN0080005

Cost-Sharing Overview

Ascension Personalized Care Balanced Silver offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Ascension Personalized Care Balanced Silver?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Ascension Personalized Care Balanced Silver offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Ascension Personalized Care Balanced Silver covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description:
Out of Service Area Coverage: No
Out of Service Area Coverage Description:
National Network: No

Additional Benefits and Cost-Sharing

Ascension Personalized Care Balanced Silver includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
No Charge after deductible 100.00%
Specialist Visit
Covered
No Charge after deductible 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
No Charge after deductible 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
No Charge after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
No Charge after deductible 100.00%
Hospice Services
Covered
No Charge after deductible 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
No Charge after deductible 100.00%82 Visit(s) per Year
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
No Charge after deductible 100.00%
Home Health Care Services
Covered
No Charge after deductible 100.00%100 Visit(s) per Benefit Period Combined In and out of network. Maximum does not include Home Infusion Therapy or Private Duty Nursing rendered in the home.
Emergency Room Services
Covered
No Charge after deductible No Charge after deductible
Emergency Transportation/Ambulance
Covered
No Charge after deductible No Charge after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
No Charge after deductible 100.00% Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network.
Inpatient Physician and Surgical Services
Covered
No Charge after deductible 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
No Charge after deductible 100.00%90 Days per Benefit Period Limit is combined both In and Out of Network.
Prenatal and Postnatal Care
Covered
No Charge after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
No Charge after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
No Charge after deductible 100.00% Cost share driven by provider/setting.
Mental/Behavioral Health Inpatient Services
Covered
No Charge after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
No Charge after deductible 100.00% Cost share driven by provider/setting.
Substance Abuse Disorder Inpatient Services
Covered
No Charge after deductible 100.00%
Generic Drugs
Covered
No Charge after deductible 100.00%
Preferred Brand Drugs
Covered
No Charge after deductible 100.00%
Non-Preferred Brand Drugs
Covered
No Charge after deductible 100.00%
Specialty Drugs
Covered
No Charge after deductible 100.00%
Outpatient Rehabilitation Services
Covered
No Charge after deductible 100.00%60 Visit(s) per Benefit Period Cost share is driven by provider/setting. Coverage for Speech Therapy is limited to 20 visits per benefit period, Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to 20 visits per benefit period. These limits are combined in and out of network. Benefit includes an Inpatient maximum of 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network. Cardiac Rehabilitation limited to 36 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non-Network when rendered in the home, Home Care Services limits apply.Pulmonary Rehabilitation limited to 20 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non-Network. When rendered in the home, Home Care Services limits apply. When rendered as part of physical therapy, the Physical Therapy limit will apply instead of the limit indicated.
Habilitation Services
Covered
No Charge after deductible 100.00%60 Visit(s) per Benefit Period Cost share is driven by provider/setting. Habilitation and rehabilitation visits count toward the rehabilitation limit. PT, OT and ST include an additional 20 visits each for habilitative services. Limits are combined both In and Out of Network.
Chiropractic Care
Covered
No Charge after deductible 100.00%12 Visit(s) per Benefit Period Limit combined In and out of network. Cost share driven by provider/setting.
Durable Medical Equipment
Covered
No Charge after deductible 100.00% One wig per benefit period combined both In and Out of Network. Network and Non-Network for wigs following cancer treatment.
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
No Charge after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge No Charge 100.00%
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge after deductible 100.00%1 Exam(s) per Year
Eye Glasses for Children
Covered
No Charge after deductible 100.00%1 Item(s) per Year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
No Charge after deductible 100.00%20 Visit(s) per Benefit Period Combined In and out of network. Cost share driven by provider/setting.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
No Charge after deductible 100.00%40 Visit(s) per Benefit Period Cost share is driven by provider/setting. Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to a separate 20 visits per benefit period. Both apply to In-Network Providers and Non-Network Providers combined. Coverage also includes an additional 20 visits each for habilitative services.
Well Baby Visits and Care
Covered
No Charge No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
No Charge after deductible 100.00% Cost share driven by provider/setting.
X-rays and Diagnostic Imaging
Covered
No Charge after deductible 100.00% Cost share driven by provider/setting.
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
No Charge after deductible 100.00% Includes coverage for unrelated donor search services ($30,000 per transplant/network & Non network combined) and travel/lodging as approved by the plan ($10,000 per transplant/network & Non network combined).
Accidental Dental
Covered
No Charge after deductible 100.00%3000 Dollars per Episode The limit will not apply to Outpatient facility charges, anesthesia billed by a Provider other than the Physician performing the service, or to services that we are required by law to cover. Cost share is driven by provider/setting. Limited to $3,000/accident; combined In and Out of network. Benefits for Accidental Dental are based on the setting in which Covered Services are recommended.
Dialysis
Covered
No Charge after deductible 100.00%
Allergy Testing
Covered
No Charge after deductible 100.00% Cost share driven by provider/setting.
Chemotherapy
Covered
No Charge after deductible 100.00% Cost share driven by provider/setting.
Radiation
Covered
No Charge after deductible 100.00% Cost share driven by provider/setting.
Diabetes Education
Covered
No Charge after deductible 100.00%
Prosthetic Devices
Covered
No Charge after deductible 100.00% Must be medically necessary.
Infusion Therapy
Covered
No Charge after deductible 100.00% Cost share driven by provider/setting.
Treatment for Temporomandibular Joint Disorders
Covered
No Charge after deductible 100.00%
Nutritional Counseling
Covered
No Charge after deductible 100.00% Cost share driven by provider/setting.
Reconstructive Surgery
Covered
No Charge after deductible 100.00% Certain reconstructive services required to correct a deformity caused by disease, trauma, congenital anomalies, or previous therapeutic process are covered. Coverage includes breast reconstruction on which a mastectomy has been performed. Reconstructive services required due to prior therapeutic process are payable only if the original procedure would have been a covered service under this plan.
Gender Affirming Care
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
No Charge after deductible 100.00% Includes coverage for unrelated donor search services ($30,000 per transplant/network & Non network combined) and travel/lodging as approved by the plan ($10,000 per transplant/network & Non network combined).
Accidental Dental
Covered
No Charge after deductible 100.00%3000 Dollars per Episode The limit will not apply to Outpatient facility charges, anesthesia billed by a Provider other than the Physician performing the service, or to services that we are required by law to cover. Cost share is driven by provider/setting. Limited to $3,000/accident; combined In and Out of network. Benefits for Accidental Dental are based on the setting in which Covered Services are recommended.
Dialysis
Covered
No Charge after deductible 100.00%
Allergy Testing
Covered
No Charge after deductible 100.00% Cost share driven by provider/setting.
Chemotherapy
Covered
No Charge after deductible 100.00% Cost share driven by provider/setting.
Radiation
Covered
No Charge after deductible 100.00% Cost share driven by provider/setting.
Diabetes Education
Covered
No Charge after deductible 100.00%
Prosthetic Devices
Covered
No Charge after deductible 100.00% Must be medically necessary.
Infusion Therapy
Covered
No Charge after deductible 100.00% Cost share driven by provider/setting.
Treatment for Temporomandibular Joint Disorders
Covered
No Charge after deductible 100.00%
Nutritional Counseling
Covered
No Charge after deductible 100.00% Cost share driven by provider/setting.
Reconstructive Surgery
Covered
No Charge after deductible 100.00% Certain reconstructive services required to correct a deformity caused by disease, trauma, congenital anomalies, or previous therapeutic process are covered. Coverage includes breast reconstruction on which a mastectomy has been performed. Reconstructive services required due to prior therapeutic process are payable only if the original procedure would have been a covered service under this plan.
Gender Affirming Care
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following Ascension Personalized Care Balanced Silver preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Ascension Personalized Care Balanced Silver including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Ascension Personalized Care Balanced Silver?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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