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 1

In-Network

Out-Of-Network

Deductible

Individual

Family

 

$1,000

$2,000

 

$3,000

$6,000

Out-Of-Pocket Maximum

Individual

Family

 

$2,000

$6,000

 

$6,000

$18,000

Preventive Care

No Charge

No Charge

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay

$25 Copay

10%*

 

$40 Copay

$40 Copay

20%*

Urgent Care Services

$25 Copay

$40 Copay

Complex Imaging: MRI/CT/PET Scans

No Charge

20%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

10%*

10%*

 

20%*

20%*

Outpatient Procedures

Facility Fee

Physician Fee

 

10%*

10%*

 

20%*

20%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

10%*

10%*

 

10%*

10%*

Mental Health / Chemical Dependency

Inpatient

Outpatient

 

10%*

$25 Copay

 

20%*

$40 Copay

Prescription Out-of-Pocket Maximum

Individual

Family

 

$1,000

$2,000

 

$1,000

$2,000

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$5 Copay

$30 Copay

$60 Copay

$5/$30/$60 Copay

Mail Order 90 day Supply

$10 Copay

$60 Copay

$120 Copay

Not Available

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

No Charge

$85 Copay

No Charge

No Charge

No Charge

 

Not Applicable

Not Applicable

Not Applicable

Not Applicable

Not Applicable

NOTE: * Coinsurance After Deductible

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

 

 

 

 


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