Geisinger Marketplace All-Access HMO 20/50/3250
Geisinger Marketplace All-Access HMO 20/50/3250 is a Gold HMO plan by Geisinger Health Plan.
Locations
Geisinger Marketplace All-Access HMO 20/50/3250 is offered in the following counties.
Plan Overview
Insurer: | Geisinger Health Plan |
Network Type: | HMO |
Metal Type: | Gold |
HSA Eligible?: | No |
Plan ID: | 22444PA0010035 |
Cost-Sharing Overview
Geisinger Marketplace All-Access HMO 20/50/3250 offers the following cost-sharing.
Cost-sharing for Geisinger Marketplace All-Access HMO 20/50/3250 includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
Cost Sharing Type | Individual | Family |
---|---|---|
Out-of-Pocket Maximum: | 8700 | 8700 per person | $17400 per group |
Deductible: | 3250 | 3250 per person | $6500 per group |
Coinsurance: | 3250 per person | $6500 per group |
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Geisinger Marketplace All-Access HMO 20/50/3250 will be shown below if applicable.
Cost Sharing Type | Individual | Family |
---|---|---|
Out-of-Network Maximum: | ||
Out-of-Network Deductible: |
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
Deductible: | 3250 |
Copayment: | 10 |
Coinsurance: | 2300 |
Limit: | 0 |
Deductible: | 2300 |
Copayment: | 800 |
Coinsurance: | 0 |
Limit: | 0 |
Deductible: | 200 |
Copayment: | 600 |
Coinsurance: | 0 |
Limit: | 0 |
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.
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
Geisinger Marketplace All-Access HMO 20/50/3250 offers the following features and referral requirements.
Wellness Program: | Yes |
Disease Program: | Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Weight Loss Programs, High Blood Pressure & High Cholesterol |
Notice Pregnancy: | No |
Referral Specialist: | No |
Specialist Requiring Referral: | |
Plan Exclusions: | Acupuncture, Bariatric Surgery, Cosmetic Surgery, Hearing Aids, Long-Term/Custodial Nursing Home Care, Non-Emergency Care When Traveling Outside the U.S., Private-Duty Nursing, Routine Foot Care, Weight Loss Programs, Adult Dental Care, Adult Orthodontia |
Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what Geisinger Marketplace All-Access HMO 20/50/3250 covers when you are out of the service area or out of the country.
Out of Country Coverage: | Yes |
Out of Country Coverage Description: | Emergent and urgent care covered |
Out of Service Area Coverage: | Yes |
Out of Service Area Coverage Description: | Emergent and urgent care covered. Other services covered with precertification. |
National Network: | No |
Additional Benefits and Cost-Sharing
Geisinger Marketplace All-Access HMO 20/50/3250 includes the following benefits at the cost sharing rates listed below.
Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
---|---|---|---|
Inherited Metabolic Disorder – PKU Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Additional EHB Benefit |
Habilitation Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Additional EHB Benefit |
Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
Acupuncture Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
Durable Medical Equipment Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
Laboratory Outpatient and Professional Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
Specialty Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Includes high-cost medications, often used to treat rare conditions, and may require special handling or training for use. A maximum of a 34-day supply may be dispensed for medications in this tier unless a shorter duration is specified in the formulary. Prior authorization or quantity limits may apply. Cost Share for certain medications may be set higher than standard Cost Share in order to reduce pharmacy costs by obtaining the maximum coupon assistance from manufacturer programs. Actual Member Cost Share will be adjusted to the Member’s regular medication Cost Share so the Member’s actual out-of-pocket amount will remain the same or lower. Where applicable, and as allowed by state and/or federal law, the value of any manufacturer coupon assistance will not apply towards the accumulator total of the Member’s annual Deductible or Maximum Out-of-Pocket. Only the Member’s actual amount paid after the coupon assistance will be applied to the Member’s annual Deductible or Maximum Out-of-Pocket. Please call the Pharmacy Customer Service Department at 800-988-4861 for specific cost sharing limitations. |
Rehabilitative Speech Therapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Includes treatment for the correction of a speech impairment resulting from disease, Surgery, injury, congenital anomalies, or previous therapeutic processes. Coverage will also include services by a speech therapist.Additional EHB Benefit |
Routine Dental Services (Adult) Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
Hospice Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Respite Care: If the Member were to receive Hospice Care primarily in the home, the Member’s primary caregiver may need to be relieved, maximum of seven days every six months. In such a case, the Health Benefit Plan will provide coverage for the Member to receive the same kind of care in a participating facility. |
Weight Loss Programs Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
Dental Check-Up for Children Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 1 Exam(s) per 6 Months Up to age 19 |
Primary Care Visit to Treat an Injury or Illness Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
Long-Term/Custodial Nursing Home Care Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
Prenatal and Postnatal Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Pre-notification: The Health Benefit Plan should be notified of the need for maternity care within one month of the first prenatal visit to the Physician or midwife. |
Generic Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Includes most generic medications. Prior authorization is usually not necessary for medications in this tier. 90 day supply at a retail pharmacy available for two, 30 day copayments. 90 day supply available at mail order for the same copayment as 30 days at retail. |
Treatment for Temporomandibular Joint Disorders Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
Non-Preferred Brand Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Includes certain formulary brand name medications, certain brand name medications with a generic equivalent, and non-formulary brand name medications (if approved). Prior authorization may be necessary for medications in this tier. 90 day supply at a retail pharmacy available for two, 30 day copayments. 90 day supply available at mail order for the same copayment as 30 days at retail. |
Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Occupational Therapy: Coverage will also include services rendered by a registered, licensed occupational therapist. Physical Therapy: Includes treatment by physical means, heat, hydrotherapy or similar modalities, physical agents, bio- mechanical and neuro-physiological principles, and devices to relieve pain, restore maximum function, and prevent disability following disease, injury, or loss of body part.Additional EHB Benefit |
Reconstructive Surgery Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | The Health Benefit Plan will provide coverage for the following when performed after a mastectomy: Surgery to reestablish symmetry or alleviate functional impairment, including, but not limited to: Augmentation; Mammoplasty; Reduction mammoplasty; and Mastopexy. |
Emergency Transportation/Ambulance Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
Chiropractic Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 20 Visit(s) per Benefit Period |
Basic Dental Care – Adult Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
Mental/Behavioral Health Outpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
Transplant Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
Diabetes Education Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | When prescribed by a Participating Professional Provider legally authorized to prescribe such items under law, the Health Benefit Plan will provide coverage for diabetes Outpatient self management training and education, including medical nutrition. |
Orthodontia – Adult Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
Emergency Room Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
Mental/Behavioral Health Inpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
Infusion Therapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Infusion therapy includes all professional services, supplies, and equipment that are required to safely and effectively administer the therapy. |
Routine Foot Care Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
Urgent Care Centers or Facilities Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
X-rays and Diagnostic Imaging Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | CT/PET scans, MRIs and other specialty imaging are not included in this category. |
Allergy Testing Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
Outpatient Rehabilitation Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 36 Visit(s) per Benefit Period Visit limit applies to Cardiac Rehabilitation Therapy, Pulmonary/Respiratory Therapy. |
Imaging (CT/PET Scans, MRIs) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
Preventive Care/Screening/Immunization Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
Skilled Nursing Facility Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 120 Days per Benefit Period |
Inpatient Physician and Surgical Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | The Health Benefit Plan will provide coverage for surgical services provided: By a Participating Professional Provider, and/or a Participating Facility Provider; For the treatment of disease or injury. |
Diabetes Care Management Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Additional EHB Benefit |
Chemotherapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Chemotherapeutic agents, if administered intravenously or intramuscularly (through intraarterial injection, infusion, perfusion or subcutaneous, intracavitary and oral routes) will be covered. |
Bariatric Surgery Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
Private-Duty Nursing Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
Routine Eye Exam (Adult) Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
Eye Glasses for Children Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 1 Item(s) per Year Up to age 19 |
Well Baby Visits and Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
Specialist Visit Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | No referral required. Includes Physician Assistants or other practitioners in Specialist Office. |
Dental Anesthesia Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Additional EHB Benefit |
Delivery and All Inpatient Services for Maternity Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
Major Dental Care – Child Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Up to age 19 |
Substance Abuse Disorder Outpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
Abortion for Which Public Funding is Prohibited Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
Infertility Treatment Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Infertility treatment is limited to Artificial Insemination when Facility Services are provided by a Participating Facility Provider and services are performed by a Participating Provider for the promotion of fertilization of a female recipient’s own ova (eggs). |
Orthodontia – Child Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 24 Months per Lifetime Orthodontic treatment must be Medically Necessary. Up to age 19. |
Hearing Aids Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
Dialysis Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Dialysis treatment when provided in the Outpatient facility of a Hospital, a free-standing renal Dialysis facility or in the home. In the case of home Dialysis, Covered Services will include equipment, training, and medical supplies. |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
Inpatient Hospital Services (e.g., Hospital Stay) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
Outpatient Surgery Physician/Surgical Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
Radiation Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
Accidental Dental Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | The initial treatment of Accidental Injury/trauma (That is, fractured facial bones and fractured jaws), in order to restore proper function. Restoration of proper function includes the dental services required for the initial restoration or replacement of Sound Natural Teeth, required for the initial treatment for the Accidental Injury/trauma. |
Substance Abuse Disorder Inpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
Nutritional Counseling Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 6 Visit(s) per Benefit Period Counseling visits or session need to be performed and billed by any of the following Providers, in an office setting: Member’s Physician, Specialist, or Registered Dietitian. |
Cosmetic Surgery Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
Major Dental Care – Adult Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
Preferred Brand Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Includes certain formulary brand name medications with no generic equivalent. Prior authorization may be necessary for medications in this tier. 90 day supply at a retail pharmacy available for two, 30 day copayments. 90 day supply available at mail order for the same copayment as 30 days at retail. |
Routine Eye Exam for Children Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 1 Exam(s) per Year Up to age 19 |
Basic Dental Care – Child Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Up to age 19 |
Home Health Care Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 60 Visit(s) per Benefit Period |
Prosthetic Devices Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes |
Free Preventive Services
There is no copayment or coinsurance for any of the following Geisinger Marketplace All-Access HMO 20/50/3250 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.
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
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