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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

$1,000 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$1,000

$3,000

 

$1,500

$6,000

Out-of-Pocket Maximum

Individual

Family

 

$4,000

$8,000

 

$6,000

$13,500

Preventive Care Services

No Charge

No Coverage

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$75 Copay

$75 Copay

$75 Copay

 

50%*

50%*

50%*

Urgent Care Services

$75 Copay

$75 Copay

Complex Imaging: MRI/CT/PET Scans

30%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

30%*

30%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

30%*

30%*

 

50%*

50%*

Emergency Room

Facility Fee

Physician Fee

Emergency Medical Transportation

 

$200 Copay

No Charge

30%*

 

$200 Copay

No Charge

30%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

30%*

$35 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$25 Copay

$65 Copay

$125 Copay

20%* up to $400

Mail Order 90 Day Supply

$50 Copay

$130 Copay

$250 Copay

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$2,000 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$2,000

$4,000

 

$3,000

$9,000

Out-of-Pocket Maximum

Individual

Family

 

$5,000

$10,000

 

$7,500

$15,000

Preventive Care Services

No Charge

No Coverage

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

20%*

20%*

20%*

 

50%*

50%*

50%*

Urgent Care Services

20%*

20%*

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 Room

Emergency Medical Transportation

20%*

20%*

20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

20%*

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$25 Copay

$65 Copay

$125 Copay

20%* up to $400

Mail Order 90 Day Supply

$50 Copay

$130 Copay

$250 Copay

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$3,500 HSA Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$3,500

$7,000

 

$5,250

$10,500

Out-of-Pocket Maximum

Individual

Family

 

$5,000

$10,000

 

$8,900

$17,800

Preventive Care Services

No Charge

No Coverage

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

20%*

20%*

20%*

 

50%*

50%*

50%*

Urgent Care Services

20%*

20%*

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 Room

Facility Fee

Physician Fee

Emergency Medical Transportation

 

20%*

20%*

20%*

 

20%*

20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

20%*

 

50%*

50%*

Prescription Drug Coverage

Expanded Preventive - Generic

Expanded Preventive - Preferred Brand

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

No Charge

No Charge

20%*

20%*

30%*

20%*

Mail Order 90 Day Supply

No Charge

No Charge

20%*

20%*

30%*

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

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