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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

Copay Plan 1

In-Network

Out-of-Network

Deductible

Individual

Individual under Family

Family

 

$1,000

$1,000

$2,000

 

$1,000

$1,000

$2,000

Out-of-Pocket Maximum

Individual

Individual under Family

Family

 

$2,500

$2,500

$2,500

 

$2,500

$2,500

$2,500

Preventive Care Services

No Charge

No Charge

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$10 Copay

$10 Copay

$10 Copay

 

30%*

30%*

$10 Copay

Urgent Care Services

0%*

0%*

Complex Imaging: MRI/CT/PET Scans

No Charge

30%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

30%*

30%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

30%*

30%*

Emergency Room

Emergency Medical Transportation

0%*

0%*

0%*

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$10 Copay

 

30%*

30%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$15 Copay

$25 Copay

$25 Copay

Not Covered

Mail Order 90 Day Supply

$30 Copay

$50 Copay

$50 Copay

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

Copay Plan 2

In-Network

Out-of-Network

Deductible

Individual

Individual under Family

Family

 

$500

$500

$1,000

 

$500

$500

$1,000

Out-of-Pocket Maximum

Individual

Individual under Family

Family

 

$2,500

$2,500

$2,500

 

$2,500

$2,500

$2,500

Preventive Care Services

No Charge

No Charge

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$10 Copay

$10 Copay

$10 Copay

 

30%*

30%*

$10 Copay

Urgent Care Services

0%*

0%*

Complex Imaging: MRI/CT/PET Scans

No Charge

30%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

30%*

30%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

30%*

30%*

Emergency Room

Emergency Medical Transportation

0%*

0%*

0%*

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$10 Copay

 

30%*

30%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$15 Copay

$25 Copay

$25 Copay

Not Covered

Mail Order 90 Day Supply

$30 Copay

$50 Copay

$50 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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