| 2 Plan Options | Value Care – Value Plan 110 | Value Care – Value Plan 125 Rx Valet Complete Plus. |
|---|---|---|
| Primary & Urgent Care (Sanitas Medical Center) | • Over 160 rutin medical services at Zero-Cost to members. • Unlimited Primary Care Visits (on-site) • Unlimited Telehealth Visits • 2 Urgent Care Visits then $99. Each • X-Rays* • Ultrasound* • Laboratory* • Sick and Wellness Screenings | • Over 160 rutin medical services at Zero-Cost to members. • Unlimited Primary Care Visits (on-site) • Unlimited Telehealth Visits • 2 Urgent Care Visits then $99. Each • X-Rays* • Ultrasound* • Laboratory* • Sick and Wellness Screenings |
| Prescription Drug Rx Card (Rx Valet) | Rx Valet NOT INCLUDED Discounts at Select Sanitias locations | RX VALET COMPLETE PLUS-Over 800 routinely prescribed ACUTE and CHRONIC medications at Zero-Cost to members. Allergy Arthritis/Pain Blood Pressure/Heart Cholesterol Cold/Cough Diabetes Men/Women’s Health Mental Health Pink Eye and Much More! Program, We also offer a Prescription Assistance Program (PAP) for many medications over $200. This can save up to thousands of dollars. Discount at Select Sanitas locations. |
| Dental Savings (Aetna Dental Access) | Save between 15%-50% on dental care. • Choose from a network of over 110,000 participating provider locations including general dentists and specialists. | Save between 15%-50% on dental care. • Choose from a network of over 110,000 participating provider locations including general dentists and specialists. |
| Vision Savings (Eye Med) | Save 35% off normal retail prices on frames (complete pair) and 20% off lens add-ons • Visit participating retailers such as Lens Crafters®, Sears Optical®, Target Optical®, JCPenney® Optical and most Pearle Vision® locations • Choose from more than 65,000 providers in over 26,000 locations. | Save 35% off normal retail prices on frames (complete pair) and 20% off lens add-ons • Visit participating retailers such as Lens Crafters®, Sears Optical®, Target Optical®, JCPenney® Optical and most Pearle Vision® locations • Choose from more than 65,000 providers in over 26,000 locations. |
| Hearing Savings (Connect Heariing) | • 35% discount off Connect Hearing’s hearing aid prices • 3 years of free batteries with hearing aid purchase† • 3 year warranty and 3 year loss & damage* • Free earmolds • Complimentary hearing evaluation • Unlimited follow-up visits during the useful life of the hearing aid for cleaning and check ups • 100% Service Satisfaction Guarantee • 45 day trial period after purchase during which you may return your hearing aids if you are not satisfied • Up to two free accessories with purchase of select models • 2 week free hearing aid trial prior to purchase** | • 35% discount off Connect Hearing’s hearing aid prices • 3 years of free batteries with hearing aid purchase† • 3 year warranty and 3 year loss & damage* • Free earmolds • Complimentary hearing evaluation • Unlimited follow-up visits during the useful life of the hearing aid for cleaning and check ups • 100% Service Satisfaction Guarantee • 45 day trial period after purchase during which you may return your hearing aids if you are not satisfied • Up to two free accessories with purchase of select models • 2 week free hearing aid trial prior to purchase** |
| Chiropractic & Alternative Medicine Savings (Choose Healthy) | discounts of 25% off usual and customary fees for services from a national network of complementary health care providers. • Choose from over 19,000 participating providers nationwide Participating chiropractors, massage therapists and acupuncturists There is no limit to the number of visits, and services are not required to be medically necessary Members will also receive Fitness Center Discounts. | |
| Imaging Savings (MRI, CT Scans) (Galaxy Health Network) | Discounted advanced diagnostic imaging at over 2,900 radiology centers nationwide. Savings range from 40% to 75% off MRI’s and CT Scans. | Discounted advanced diagnostic imaging at over 2,900 radiology centers nationwide. Savings range from 40% to 75% off MRI’s and CT Scans. |
| Lab Services (Direct Labs) | Direct access to major clinical labs across the USA* for important blood tests at discounted prices. Services include lab, blood, fecal, urine, saliva and hair tests. • All blood tests are offered at a savings of 20% – 80% off typical lab costs and through the same CLIA-certified accredited labs used by your physician. | Direct access to major clinical labs across the USA* for important blood tests at discounted prices. Services include lab, blood, fecal, urine, saliva and hair tests. • All blood tests are offered at a savings of 20% – 80% off typical lab costs and through the same CLIA-certified accredited labs used by your physician. |
| Other services Not Covered. | In and out Patient Hospitalization Emergency Chiropractic Care Speech & Occupational Therapy Home Health care Hospice Care Skilled Nursing Facility Durable Medical Equipment Prosthetics, Orthotics, Supplies & Surgical Dressings Dialysis Transplant services | In and out Patient Hospitalization Emergency Chiropractic Care Speech & Occupational Therapy Home Health care Hospice Care Skilled Nursing Facility Durable Medical Equipment Prosthetics, Orthotics, Supplies & Surgical Dressings Dialysis Transplant services |
| THIS IS NOT INSURANCE. VCHP is a capitated Direct Primary Care healthcare model. *Limitations and Exclusions apply. See the full benefits summary for further details. | THIS IS NOT INSURANCE. VCHP is a capitated Direct Primary Care healthcare model. *Limitations and Exclusions apply. See the full benefits summary for further details. | |
| NO RX Card & Discunt Only | Full Formualy Rx Card, Zero-Cost 800 Rx | |
| Individual | $110.00 | $125.00 |
| Individual + Spouse | $170.00 | $187.00 |
| Individual + 1 Child | $178.75 | $195.75 |
| Family with 1 Child | $238.75 | $257.75 |
| Each additional Child Add | $58 | $58 |
| One-time registration fee per person | $50 | $50 |
| PLAN | Value Plan 110 | Value Plan 125- RxValet 800Rx $0 |
|---|---|---|
| Deductible (Individual/Family) | $0/$0 | $0/$0 |
| Maximum Out of Pocket (Individual/Family) | Not Applicable | Not Applicable |
| Preventive Care | Preventive Care | Preventive Care |
| Routine Well Care (Sanitas in-network) | Included | Included |
| Routine Well Care (In Hospital Services) | Not covered | Not covered |
| Physician Services | Physician Services | Physician Services |
| Primary Care Office Visit (Includes mental & behavioral health) | Unlimited | Unlimited |
| Specialist Office Visit (Limited to Availability Sanitas in-network)* | Included* | Included* |
| Allergy Services | Included | Included |
| Limited: Other Services Performed in Physician Office Sanitas in-network | Included | Included |
| Telemedicine (Unlimited) | $0 Copay | $0 Copay |
| Urgent Care (Limited 2 per year Discounted Cash pay after)* | Included* | Included* |
| Diagnostic Testing* | Diagnostic Testing* | Diagnostic Testing* |
| Radiology & Advanced Imaging (When utilizing Sanitas) | Discounted / Cash-Pay | Discounted / Cash-Pay |
| Radiology (Non-Hospital Services) (Sanitas Only w/ limitations to basic X-Ray)* | Included* | Included* |
| Advanced Imaging (Non-Hospital Services) (Sanitas) | Discounted / Cash-Pay | Discounted / Cash-Pay |
| Laboratory (Non-Hospital Services) (Lab services at Sanitas) | Included* | Included* |
| Laboratory, Radiology & Advanced Imaging (Hospital Services) | Not covered | Not covered |
| Hospital, Emergency, & Facility Services* | Hospital, Emergency, & Facility Services* | Hospital, Emergency, & Facility Services* |
| Ambulance | Not covered | Not covered |
| Emergency | Not covered | Not covered |
| Hospital Admission Benefits (Included under APL) | Not covered | Not covered |
| Hospital Confinement Benefits (Included under APL) | Not covered | Not covered |
| Intensive Care Unite Admission Benefit (Included under APL) | Not covered | Not covered |
| Intensive Care Unite Benefit (Included under APL) | Not covered | Not covered |
| Ambulatory Surgical or Outpatient Surgical Facility (Included under APL)* | Not covered | Not covered |
| Accident & Sickness Surgery Benefit | Accident & Sickness Surgery Benefit | Accident & Sickness Surgery Benefit |
| Outpatient Surgery in a Hospital, Outpatient Facility or Freestanding Surgery Center | Not covered | Not covered |
| Outpatient Surgery in a Physician’s Office | Not covered | Not covered |
| Second Surgical Opinion | Not covered | Not covered |
| Pharmacy Benefits Retail Option – 30 day Supply | Pharmacy Benefits Retail Option – 30 day Supply | Pharmacy Benefits Retail Option – 30 day Supply |
| Preventive Generic Drugs | Discounted / Cash-Pay, Sanitas Only | Rx Valet over 800 Drugs @ Zero-Cost with Heavy Discounts on other brands |
| Generic Drugs | Discounted / Cash-Pay, Sanitas Only | Rx Valet over 800 Drugs @ Zero-Cost with Heavy Discounts on other brands |
| Specialty Drugs, and Preferred & Non-Preferred Brand | Not covered | Rx Valet (PAP) Prescription assistance program for any drug over $200 visit MyRxValet.com |
| Retail Option – 90-day Supply | Retail Option – 90-day Supply | Retail Option – 90-day Supply |
| Generic Drugs / Medicamentos Genéricos | Discounted / Cash-Pay, Sanitas Only | High Dose Qty (Rx Valet) |
| Specialty Drugs, and Preferred & Non-Preferred Brand / Medicamentos Especializados, y Marca Preferida y No Preferida | Not covered | High Dose Qty (Rx Valet) |
| Other Services Performed at Sanitas providers In-Network ONLY | ||
| Laboratory Basic Panel | Laboratory Basic Panel | Laboratory Basic Panel |
| Venipuncture | Included | Included |
| Hemoglobin A1C | Included | Included |
| Fasting Glucose | Included | Included |
| Hemoglobin | Included | Included |
| Rapid Flu | Included | Included |
| Rapid Strep | Included | Included |
| Urine Pregnancy Test | Included | Included |
| Urinalysis | Included | Included |
| Urinalysis, no micro | Included | Included |
| Urine Dip | Included | Included |
| CBC | Included | Included |
| PSA | Included | Included |
| Lipid panel | Included | Included |
| Pap smear | Included | Included |
| HIV testing | Included | Included |
| Hepatitis B testing | Included | Included |
| Hepatitis C testing | Included | Included |
| Complete Metabolic Panel | Included | Included |
| TSH | Included | Included |
| T4 | Included | Included |
| Chlamydia w/ Gonorrhea | Included | Included |
| Gonorrhea | Included | Included |
| RPR | Included | Included |
| Urine Culture | Included | Included |
| Helicobacter Pylori (H. Pylori) | Included | Included |
| Laboratory Basic Panel | Laboratory Basic Panel | Laboratory Basic Panel |
| EKG | Included | Included |
| Immunization Administration | Included | Included |
| Influenza Vaccine, Live, Intranasal | Included | Included |
| Visual Acuity Screening | Included | Included |
| Mammography | Self-Pay | Self -Pay |
| Diagnostic mammography (UNILATERAL) | $171.00 | $171 |
| Diagnostic mammography (BILATERAL) | $217.00 | $217 |
| Diagnostic mammography (BILATERAL) (YEARLY) | $175.00 | $175.00 |
| Screenings | Screenings | Screenings |
| DAX Bone Density AXIAL | $45 | $45 |
| Psychiatric Screenings (PHQ2 and PHQ9) | Included | Included |
| Vital Signs | Included | Included |
| Blood Pressure | Included | Included |
| Body Mass Index | Included | Included |
| Weight Recorded | Included | Included |
| Ocular Instrument Screening (Eyes) | Included | Included |
| Developmental Testing | Included | Included |
| Cognitive Testing | Included | Included |
| Dilated Retina Exam Interpretation | Included | Included |
| Visual Accuity Screening | Included | Included |
| Tobacco User Screening | Included | Included |
| Audiometry Screening (Hearing Test) | Included | Included |
| Human Papillomavirus | Included | Included |
| Primary Care | Primary Care | Primary Care |
| Medication Review and Documentation | Included | Included |
| Pain notated, persistent | Included | Included |
| Screening Follow-up | Included | Included |
| Brief Emotional Behavior Assessment | Included | Included |
| Clinical Depression Screening | Included | Included |
| Medical Nutrition Counseling | Included | Included |
| Medical Nutrition Counseling Follow-up | Included | Included |
| Medical Nutrition Counseling (Group) | Included | Included |
| Health Risk Assessment (Questionnaire) | Included | Included |
| Removal of cerumen with instrument (ear wax) | Included | Included |
| Ear Lavage | Included | Included |
| Counseling – Individual (15 minutes) | Included | Included |
| Team Counseling with Patient | Included | Included |
| Telephone Visit (5-10 minutes) | Included | Included |
| Telephone Visit (11-20 minutes) | Included | Included |
| Telephone Visit (21-30 minutes) | Included | Included |
| Oral Evaluation, Patient <3 years old | Included | Included |
| Fall Risk Assessment | Included | Included |
| Foot Exam | Included | Included |
| Functional Status Assessed | Included | Included |
| Drain/Injection of Joint/Bursa | Included | Included |
| Removal of Foreign Body | Included | Included |
| Wound Care, non-selective | Included | Included |
| Albuterol Inhaler – Unit dose 1mg (rescue only) | Included | Included |
| Infusion Normal Saline Solution (rescue only) | Included | Included |
| Injection, insulin, 5 units (rescue only) | Included | Included |
| Lactated Ringers, IV Solution 500ml | Included | Included |
| Sodium Chloride 0.9% IV Solution, 1000 ml | Included | Included |
| Ipratropium Bromide Inhaler Solution | Included | Included |
| X-RAY | X-RAY | X-RAY |
| X Ray Sinuses, 3 or more views | Included | Included |
| X Ray Neck, soft tissue | Included | Included |
| X Ray Chest 2 views | Included | Included |
| X Ray Chest 2 views, PA and lat | Included | Included |
| X Ray Ribs 3 views, bilateral | Included | Included |
| X Ray Cervical spine, 3 or more views | Included | Included |
| X Ray Cervical spine, minimum 4 views | Included | Included |
| X Ray Thoracic spine, 2 views | Included | Included |
| X Ray Thoracolumbar, 2 views | Included | Included |
| X Ray Lumbosacral, 2 or 3 views | Included | Included |
| X Ray Spine lumbosacral (4 or more views) | Included | Included |
| X Ray Lumbosacral compl c/bend, min 6 views | Included | Included |
| X Ray Pelvis, 1 or 2 views | Included | Included |
| X Ray Pelvis, minimum 3 views | Included | Included |
| X Ray Sacrum & coxis, minimum 2 views | Included | Included |
| X Ray Clavicle, complete | Included | Included |
| X Ray Scapula, complete | Included | Included |
| X Ray Shoulder, minimum 2 views | Included | Included |
| X Ray Humerus, minimum 2 views | Included | Included |
| X Ray Elbow, 2 views | Included | Included |
| X Ray Elbow, minimum 3 views | Included | Included |
| X Ray Forearm, 2 views | Included | Included |
| X Ray Wrist 2 views | Included | Included |
| X Ray Hand, 2 views | Included | Included |
| X Ray Hand, minimum 3 views | Included | Included |
| X Ray finger, minimum 2 views | Included | Included |
| X Ray Hips, lower extremities | Included | Included |
| X Ray Hips, bilateral with AP pelvis | Included | Included |
| X Ray Bilateral hips, with pelvis, 2 views | Included | Included |
| X Ray Bilateral hips, with pelvis, 5 views | Included | Included |
| X Ray Femur, 2 views | Included | Included |
| X Ray Knee, 1 or 2 views | Included | Included |
| X Ray Knee, 3 views | Included | Included |
| X Ray Knee, 4 or more views | Included | Included |
| X Ray Ankle, minimum 3 views | Included | Included |
| X Ray Foot, 2 views | Included | Included |
| X Ray Foot, minimum 3 views | Included | Included |
| X Ray Calcaneus (Heel) minimum 2 views | Included | Included |
| X Ray Toes, minimum 2 views | Included | Included |
| X Ray Abdomen, single view | Included | Included |
| X Ray Abdomen, 1 view | Included | Included |
| X Ray Abdomen, 2 views | Included | Included |
| X Ray Abdomen, supine and erect | Included | Included |
| Ultrasound | Ultrasound | Ultrasound |
| Ultrasound measurement of pos ovoidal residue | Included | Included |
| Ultrasound Soft tissue head/neck B-scan in real time | Included | Included |
| Ultrasound Breast unilateral, complete | Included | Included |
| Ultrasound Breast unilateral, limited | Included | Included |
| Ultrasound Breast Bilateral, limited | Included | Included |
| Abdominal Ultrasound, B-scan and/or real time | Included | Included |
| Ultrasound abdominal limited, single organ | Included | Included |
| Ultrasound Renal/Aorta, complete B-scan in real time | Included | Included |
| Ultrasound Retroperitoneal, limited | Included | Included |
| Ultrasound Transvaginal | Included | Included |
| Pelvic Ultrasound (non ob) B-scan and/or in real time | Included | Included |
| Ultrasound Pelvic non ob, follow up or repeat | Included | Included |
| Ultrasound Scrotum and contents | Included | Included |
| Ultrasound Extrem, non vasc, complete | Included | Included |
| Ultrasound Extrem, non vasc, limited | Included | Included |
| Ultrasound Abdomen Back Wall Complete | Included | Included |
| Other Services | Other Services | Other Services |
| Maternity | Not covered | Not covered |
| Mental or Nervous Disorders or Substance Abuse (Office Visits) | Limited Services through Sanitas Health | Limited Services through Sanitas Health |
| Chiropractic Care | HUB Discount Plan | HUB Discount Plan |
| Speech Therapy | Limited Services through Sanitas | Limited Services through Sanitas |
| Physical Therapy | Not covered | Not covered |
| Occupational Therapy | Not covered | Not covered |
| Home Health Care | Not covered | Not covered |
| Hospice Care | Not covered | Not covered |
| Skilled Nursing Facility | Not covered | Not covered |
| Durable Medical Equipment (DME) | Not covered | Not covered |
| Prosthetics, Orthotics, Supplies & Surgical Dressings | Not covered | Not covered |
| Dialysis | Not covered | Not covered |
| Transplant Services | Not covered | Not covered |