Plan Details

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 1

In-Network

Out-Of-Network

Calendar Year Deductible

Employee Only

Family

 

$1,000

$2,000

 

$3,000

$6,000

Coinsurance

10%*

20%*

Out-Of-Pocket Maximum

Employee Only

Family

 

$2,000

$6,000

 

$6,000

$18,000

Preventive Care

100% Covered

100% Covered

Office Visits

Primary Services

Specialist Services

 

$25 Copay

$25 Copay

 

$40 Copay

$40 Copay

Hospital Services

10%*

20%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

10%*

10%*

 

10%*

10%*

Urgent Care Services

$25 Copay

$40 Copay

Chiropractic Services

10%*

20%*

Teladoc Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, initial evaluation

Mental Health - Psychiatrist, ongoing session

 

100% Covered

$85 Copay

$90 Copay

$220 Copay

$100 Copay

 

100% Covered

$85 Copay

$90 Copay

$220 Copay

$100 Copay

Mental Health / Chemical Dependency

Inpatient

Outpatient

 

10%*

$25 Copay

 

20%*

$40 Copay

Retail 30 Day Supply

Mail Order 90 day Supply

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

$5 Copay

$30 Copay

$60 Copay

$5/$30/$60 Copay

 

$10 Copay

$60 Copay

$120 Copay

Not Available

* After deductible

 

 

** True emergencies covered at in-network level

 

 


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