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

Copay Plan

In-Network

Out-Of-Network

Deductible

Individual

Family

 

$2,500

$7,500

 

$7,500

$22,500

Out-Of-Pocket Maximum

Individual

Family

 

$7,150

$14,300

 

$21,450

$42,900

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

$60 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

 

$150 Copay, then 20%*

20%*

 

$150 Copay, then 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

$35 copay

$60 copay

20% Coinsurance up to $300

Mail Order 90 day Supply

$15 copay

$70 copay

$180 copay

Not Available

NOTE: * Coinsurance After Deductible

**Covered In-Network in true emergency

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

 

 

 

 

 

 


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