Plan Details

Not all coverage is the right coverage.

Your healthcare coverage is important to us. Age, family status, medical conditions, hobbies, lifestyle and a myriad of other factors will help you determine if you need a lot or a very little amount of health coverage. This summary will help you understand your plan and its coverage.

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Summary of Medical Benefits

$1,000 Copay Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Family

 

$1,000

$1,000

$3,000

 

$5,000

$5,000

$10,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$3,000

$3,000

$6,000

 

$10,000

$10,000

$20,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay

$25 Copay

$25 Copay

 

50%*

50%*

50%*

Urgent Care Services

$25 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

20%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

20%*

20%*

20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$25 Copay

 

50%*

50%*

Prescription Drug Coverage

ACA Preventive Prescriptions

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

No Charge

$20 Copay

$75 Copay

$120 Copay

Not Covered

Mail Order 90 Day Supply

No Charge

$60 Copay

$225 Copay

$360 Copay

Not Covered

NOTE: * Coinsurance after deductible

Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions

 

 

 

 

$2,500 Copay Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Family

 

$2,500

$2,500

$7,500

 

$5,000

$5,000

$10,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$5,500

$5,500

$11,000

 

$10,000

$10,000

$20,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$40 Copay

$40 Copay

$40 Copay

 

50%*

50%*

50%*

Urgent Care Services

$40 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

20%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

20%*

20%*

20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$40 Copay

 

50%*

50%*

Prescription Drug Coverage

ACA Preventive Prescriptions

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

No Charge

$20 Copay

$75 Copay

$120 Copay

Not Covered

Mail Order 90 Day Supply

No Charge

$60 Copay

$225 Copay

$360 Copay

Not Covered

NOTE: * Coinsurance after deductible

Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions

 

 

 

 

$4,500 HSA Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Family

 

$4,500

$4,500

$9,000

 

$7,500

$7,500

$15,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$4,500

$4,500

$9,000

 

$12,500

$12,500

$25,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

0%*

0%*

0%*

 

50%*

50%*

50%*

Urgent Care Services

0%*

50%*

Complex Imaging: MRI/CT/PET Scans

0%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

0%*

0%*

0%*

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

0%*

 

50%*

50%*

Prescription Drug Coverage

ACA Preventive Prescriptions

Expanded Preventive - Genertic

Expanded Preventive - Preferred Brand

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

No Charge

No Charge

No Charge

0%*

0%*

0%*

Not Covered

Mail Order 90 Day Supply

No Charge

No Charge

No Charge

0%*

0%*

0%*

Not Covered

NOTE: * Coinsurance after deductible

Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions

 

 

 

 

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