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Summary of Medical Benefits

Copay Plan 1

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Family

 

$500

$1,500

 

$10,000

$20,000

Out-of-Pocket Maximum

Individual

Family

 

$4,000

$8,000

 

$20,000

$40,000

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

30%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

30%*

30%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

30%*

30%*

 

50%*

50%*

Emergency Services

Emergency Room

Emergency Medical Transportation

 

30%*

30%*

 

30%*

30%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

30%*

$40 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$15 Copay

$50 Copay

$100 Copay

30% Coinsurance up to $400/Rx

Mail Order 90 Day Supply

$45 Copay

$150 Copay

$300 Copay

Not Available

NOTE: * Coinsurance After Deductible

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

 

 

 

 

Copay Plan 2

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Family

 

$1,500

$4,500

 

$10,000

$20,000

Out-of-Pocket Maximum

Individual

Family

 

$4,000

$8,000

 

$20,000

$40,000

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 Services

Emergency Room

Emergency Medical Transportation

 

20%*

20%*

 

20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$25 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$15 Copay

$50 Copay

$100 Copay

20% Coinsurance up to $400/Rx

Mail Order 90 Day Supply

$45 Copay

$150 Copay

$300 Copay

Not Available

NOTE: * Coinsurance After Deductible

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

 

 

 

 

Elite Copay Plan 2

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Family

 

$1,500

$4,500

 

$10,000

$20,000

Out-of-Pocket Maximum

Individual

Family

 

$4,000

$8,000

 

$20,000

$40,000

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 Services

Emergency Room

Emergency Medical Transportation

 

20%*

20%*

 

20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$25 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$15 Copay

$50 Copay

$100 Copay

20% Coinsurance up to $400/Rx

Mail Order 90 Day Supply

$45 Copay

$150 Copay

$300 Copay

Not Available

NOTE: * Coinsurance After Deductible

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

 

 

 

 

HSA Plan 1

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Family

 

$4,000

$8,000

 

$10,000

$20,000

Out-of-Pocket Maximum

Individual

Family

 

$4,000

$8,000

 

$20,000

$40,000

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 Services

Emergency Room

Emergency Medical Transportation

 

0%*

0%*

 

0%*

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

0%*

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

0%*

0%*

0%*

0%*

Mail Order 90 Day Supply

0%*

0%*

0%*

Not Available

NOTE: * Coinsurance After Deductible

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

 

 

 

 

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