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Summary of Medical Benefits

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

Calendar Year Deductible

Employee Only

Family

 

$1,000

$2,000

 

$3,000

$6,000

Out-Of-Pocket Maximum

Employee Only

Family

 

$3,200

$6,400

 

$9,600

$19,200

Preventive Care

100% Covered

50%*

Office Visits

Primary Services

Specialist Services

 

$30 Copay

$60 Copay

 

50%*

50%*

Hospital Services

20%*

50%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

$350 Copay and 20% Coinsurance

20%*

 

50%*

50%*

Urgent Care Services

$75 Copay

50%*

Mental Health / Chemical Dependency

Inpatient

Outpatient

 

20%*

$60 Copay

 

50%*

50%*

Retail 30 Day Supply

Mail Order 90 day Supply

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

$20 Copay

$50 Copay

$80 Copay

25% Coinsurance up to $450

 

$40 Copay

$100 Copay

$160 Copay

Not Available

* Coinsurance After deductible

 

 

** True emergencies covered at in-network level

 

 

HSA Plan

In-Network

Out-Of-Network

Calendar Year Deductible

Employee Only

Family

 

$3,200

$6,400

 

$10,000

$20,000

Out-Of-Pocket Maximum

Employee Only

Family

 

$3,200

$6,400

 

$20,000

$40,000

Preventive Care

100% Covered

50%*

Office Visits

Primary Services

Specialist Services

 

0%*

0%*

 

50%*

50%*

Hospital Services

0%*

50%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

0%*

0%*

 

50%*

50%*

Urgent Care Services

0%*

50%*

Mental Health / Chemical Dependency

Inpatient

Outpatient

 

0%*

0%*

 

50%*

50%*

Retail 30 Day Supply

Mail Order 90 day Supply

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

0%*

0%*

0%*

0%*

 

0%*

0%*

0%*

Not Available

* Coinsurance After deductible

 

 

** True emergencies covered at in-network level

 

 


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