Plan Details

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

In-Network

Out-Of-Network

Embedded Deductible

Individual Coverage

Individual under Family Coverage

Family Coverage

 

$200

$200

$400

 

$300

$300

$600

Embedded Out-of-Pocket Maximum

Individual Coverage

Individual under Family Coverage

Family Coverage

 

$600

$600

$1,200

 

$600

$600

$1,200

Preventive Care Services

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$10 Copay

$10 Copay

10%*

 

20%*

20%*

20%*

Urgent Care Services

$15 Copay

20%*

Complex Imaging: MRI/CT/PET Scans

10%*

20%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

10%*

10%*

 

20%*

20%*

Outpatient Procedures

Facility Fee

Physician Fee

 

10%*

10%*

 

20%*

20%*

Emergency Room Services

Emergency Medical Transportation

$50 Copay

10%*

$50 Copay

10%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

10%*

$10 Copay

 

20%*

20%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

 

$9 Copay

$9 Copay

$20 Copay

$9/$9/$20 Copay

 

$9 Copay

$9 Copay

$20 Copay

Not Available

NOTE: * Coinsurance After Deductible

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

 

 

 

 


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