Lifespan Health
Here’s a quick look at your benefits. You can find a more thorough description of benefits in the Summary of Benefits and Coverage for Lifespan Health.
Coverage | Preferred Network1 | In-Network | Out-of-Network |
|---|---|---|---|
Deductible | N/A | N/A | Individual - $2,000 |
Out-of-Pocket Maximum (accumulates separately for in- and out-of-network) | Individual - $4,000 | Individual - $4,000 | Individual - $5,000 |
Routine Physical Exams (includes all preventive services covered under the Patient Protection & Affordable Care Act) | Covered in full | Covered in full | 20% coinsurance after deductible is met |
Non-Routine Primary Care Provider Office Visits | $20 copay per visit | $30 copay per visit | 20% coinsurance after deductible is met |
Non-Routine Specialist Office Visits and Chiropractic Care | $30 copay per visit | $50 copay per visit | 20% coinsurance after deductible is met |
Physical/ Occupational/ Speech Therapy | Covered in full | $40 copay per visit | 20% coinsurance after deductible is met |
Inpatient Hospital Care and Surgery | $300 per admission | $1,000 per admission | 20% coinsurance after deductible is met |
Inpatient Maternity Care | Covered in full | Covered in full | 20% coinsurance after deductible is met |
Diagnostic Imaging (x-rays, ultrasounds) | Covered in full | $50 copay | 20% coinsurance after deductible is met |
Diagnostic Blood Work | Covered in full2 | $40 copay | 20% coinsurance after deductible is met |
Diagnostic Colonoscopies3 | $200 copay | $600 copay | 20% coinsurance after deductible is met |
Inpatient Rehabilitation (limit 100 days per year) | Covered in full | $400 copay | 20% coinsurance after deductible is met |
Inpatient Behavioral Health & Chemical Dependency | $300 copay per admission | $300 copay per admission | 20% coinsurance after deductible is met |
High-Tech Imaging (CAT scan, MRI/MRA, nuclear cardiology, PET scan) | Covered in full | $100 copay | 20% coinsurance after deductible is met |
Durable Medical Equipment | Covered in full | $40 copay per provider per day | 20% coinsurance after deductible is met |
Outpatient Day Surgery | $200 copay | $600 copay | 20% coinsurance after deductible is met |
Urgent Care Center | $30 copay per visit | $50 copay per visit | 20% coinsurance after deductible is met |
Emergency Room | $150 copay per visit | $150 copay per visit | $150 copay per visit |
1Preferred Network includes Rhode Island Hospital and its pediatric division, Hasbro Children’s Hospital; The Miriam Hospital; Newport Hospital; Bradley Hospital; Lifespan Home Medical, Gateway Healthcare, and related service locations. For a list of all providers in this network, use the Find a Doctor tool.
2A copay will apply if your lab specimen is sent out to any non-Lifespan Lab for processing.
3Preventive colonoscopies are covered once every 5 years.
This is a summary of benefits. It is not a contract. For details about coverage, including any limits and exclusions not noted here, please call (401) 429-2102 or 1-866-987-3706.
Looking for pharmacy & vision?
View pharmacy benefits on the ESI website
View vision benefits on the EyeMed website