Plan Details

Plan

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

Copay Plan

In-Network

Out-Of-Network

Deductible

Individual

Family

 

$2,000

$4,000

 

$2,000

$4,000

Out-Of-Pocket Maximum

Individual

Family

 

$4,500

$9,000

 

$9,000

$18,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay

$50 Copay

$50 Copay

 

50%*

50%*

50%*

Urgent Care Services

$50 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

30%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

30%*

30%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

$50 Copay

No Charge

 

50%*

50%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

$250 Copay

30%*

 

50%*

30%*

Mental health/Chemical Dependency

Inpatient

Office Visit

 

30%*

$50 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$20 Copay

$40 Copay

$60 Copay

Mail Order (per 30-day Supply)

30%*

Mail Order 90 day Supply

$40 Copay

$80 Copay

$120 Copay

 

Not Available

NOTE: * Coinsurance After Deductible

**Covered as in-network in true emergency

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

 

 

 

 

 

 


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