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

$1,500 Copay Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Family

 

$1,500

$1,500

$3,000

 

$4,000

$4,000

$8,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$6,600

$6,600

$13,200

 

$13,000

$13,000

$26,000

Preventive Care Services

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$30 Copay

$60 Copay

$60 Copay

 

40%*

40%*

40%*

Urgent Care Services

$60 Copay

40%*

Complex Imaging: MRI/CT/PET Scans

20%*

40%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Emergency Room

Facility Fee

Physician Fee

Emergency Medical Transportation

 

$250 Copay, then 20% Coinsurance

20% Coinsurance

20%*

 

$250 Copay, then 20% Coinsurance

20% Coinsurance

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$60 Copay

 

40%*

40%*

Prescription Drug Coverage

Preventive Prescriptions

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

No Charge

$10 Copay

$40 Copay

$80 Copay

Not Covered

Mail Order 90 Day Supply

No Charge

$25 Copay

$100 Copay

$200 Copay

Not Covered

NOTE: * Coinsurance after deductible

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

 

 

 

 

$750 Copay Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Family

 

$750

$750

$1,500

 

N/A

N/A

N/A

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$3,500

$3,500

$7,000

 

N/A

N/A

N/A

Preventive Care Services

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay

$50 Copay

$50 Copay

 

Not Covered

Not Covered

Not Covered

Urgent Care Services

$50 Copay

Not Covered

Complex Imaging: MRI/CT/PET Scans

20%*

Not Covered

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

Not Covered

Not Covered

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

Not Covered

Not Covered

Emergency Room

Facility Fee

Physician Fee

Emergency Medical Transportation

 

$250 Copay, then 20% Coinsurance

20% Coinsurance

20%*

 

$250 Copay, then 20% Coinsurance

20% Coinsurance

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$50 Copay

 

Not Covered

Not Covered

Prescription Drug Coverage

Preventive Prescriptions

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

No Charge

$10 Copay

$40 Copay

$80 Copay

Not Covered

Mail Order 90 Day Supply

No Charge

$25 Copay

$100 Copay

$200 Copay

Not Covered

NOTE: * Coinsurance after deductible

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

 

 

 

 

$5,000 Copay Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Family

 

$5,000

$5,000

$10,000

 

N/A

N/A

N/A

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$6,600

$6,600

$13,200

 

N/A

N/A

N/A

Preventive Care Services

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$40 Copay

$80 Copay

$80 Copay

 

Not Covered

Not Covered

Not Covered

Urgent Care Services

$80 Copay

Not Covered

Complex Imaging: MRI/CT/PET Scans

30%*

Not Covered

Inpatient Hospital Care

Facility Fee

Physician Fee

 

30%*

30%*

 

Not Covered

Not Covered

Outpatient Procedures

Facility Fee

Physician Fee

 

30%*

30%*

 

Not Covered

Not Covered

Emergency Room

Facility Fee

Physician Fee

Emergency Medical Transportation

 

$250 Copay, then 30% Coinsurance

30% Coinsurance

30%*

 

$250 Copay, then 30% Coinsurance

30% Coinsurance

30%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

30%*

$80 Copay

 

Not Covered

Not Covered

Prescription Drug Coverage

Preventive Prescriptions

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

No Charge

$10 Copay

$40 Copay

$80 Copay

Not Covered

Mail Order 90 Day Supply

No Charge

$25 Copay

$100 Copay

$200 Copay

Not Covered

NOTE: * Coinsurance after deductible

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

 

 

 

 

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