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Summary of Medical Benefits

Copay Plan 1

In-Network

Out-of-Network

Calendar Year Accumulation

Embedded Deductible

Employee only

Family

$500

$1,500

$10,000

$20,000

Coinsurance

30%*

50%*

Embedded Out-of-Pocket Maximum

Employee only

Family

$4,000

$8,000

$20,000

$40,000

Recuro Telemedicine Services

100% Covered

Preventive Care

100% Covered

Deductible, then 50%*

Office Visits

Primary Services

Specialist Services

Chiropractic Services

$40 Copay

Deductible, then 50%*

Urgent Care Services

$40 Copay

Deductible, then 50%*

Emergency Services

Emergency Room

Emergency Medical Transportation

Deductible, then 30%*

Hospital Services

Inpatient Hospital Facility

Outpatient Surgery

Deductible, then 30%*

Deductible, then 50%*

Diagnostic Testing & Imaging

Labs

X-rays

CT/PET/MRI

Deductible, then 30%*

Deductible, then 50%*

Mental Health/Chemical Dependency

Inpatient

Outpatient

Deductible, then 30%*

$40 Copay

Deductible, then 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

Copay Plan 2

In-Network

Out-of-Network

Calendar Year Accumulation

Embedded Deductible

Employee only

Family

$1,500

$4,500

$10,000

$20,000

Coinsurance

20%*

50%*

Embedded Out-of-Pocket Maximum

Employee only

Family

$4,000

$8,000

$20,000

$40,000

Recuro Telemedicine Services

100% Covered

Preventive Care

100% Covered

Deductible, then 50%*

Office Visits

Primary Services

Specialist Services

Chiropractic Services

$25 Copay

Deductible, then 50%*

Urgent Care Services

$25 Copay

Deductible, then 50%*

Emergency Services

Emergency Room

Emergency Medical Transportation

Deductible, then 20%*

Hospital Services

Inpatient Hospital Facility

Outpatient Surgery

Deductible, then 20%*

Deductible, then 50%*

Diagnostic Testing & Imaging

Labs

X-rays

CT/PET/MRI

Deductible, then 20%*

Deductible, then 50%*

Mental Health/Chemical Dependency

Inpatient

Outpatient

Deductible, then 20%*

$25 Copay

Deductible, then 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

Elite Copay Plan 2

In-Network

Out-of-Network

Calendar Year Accumulation

Embedded Deductible

Employee only

Family

$1,500

$4,500

$10,000

$20,000

Coinsurance

20%*

50%*

Embedded Out-of-Pocket Maximum

Employee only

Family

$4,000

$8,000

$20,000

$40,000

Recuro Telemedicine Services

100% Covered

Preventive Care

100% Covered

Deductible, then 50%*

Office Visits

Primary Services

Specialist Services

Chiropractic Services

$25 Copay

Deductible, then 50%*

Urgent Care Services

$25 Copay

Deductible, then 50%*

Emergency Services

Emergency Room

Emergency Medical Transportation

Deductible, then 20%*

Hospital Services

Inpatient Hospital Facility

Outpatient Surgery

Deductible, then 20%*

Deductible, then 50%*

Diagnostic Testing & Imaging

Labs

X-rays

CT/PET/MRI

Deductible, then 20%*

Deductible, then 50%*

Mental Health/Chemical Dependency

Inpatient

Outpatient

Deductible, then 20%*

$25 Copay

Deductible, then 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

HSA Plan 1

In-Network

Out-of-Network

Calendar Year Accumulation

Embedded Deductible

Employee only

Family

$4,000

$8,000

$10,000

$20,000

Coinsurance

0%*

50%*

Embedded Out-of-Pocket Maximum

Employee only

Family

$4,000

$8,000

$20,000

$40,000

Recuro Telemedicine Services

100% Covered

Preventive Care

100% Covered

Deductible, then 50%*

Office Visits

Primary Services

Specialist Services

Chiropractic Services

Deductible, then 0%*

Deductible, then 50%*

Urgent Care Services

Deductible, then 0%*

Deductible, then 50%*

Emergency Services

Emergency Room

Emergency Medical Transportation

Deductible, then 0%*

Hospital Services

Inpatient Hospital Facility

Outpatient Surgery

Deductible, then 0%*

Deductible, then 50%*

Diagnostic Testing & Imaging

Labs

X-rays

CT/PET/MRI

Deductible, then 0%*

Deductible, then 50%*

Mental Health/Chemical Dependency

Inpatient

Outpatient

Deductible, then 0%*

Deductible, then 50%*

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

Deductible, then 0%*

Mail Order 90 Day Supply

Deductible, then 0%*

Not Available

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

An Embedded Deductible means that each individual will only have to meet the individual Deductible before the Plan begins paying benefits for such individual that are subject to a Deductible.

An Embedded Out-of-Pocket Maximum means that each individual will only have to meet the individual out-of-pocket maximum before the Plan begins paying in full for such individual

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