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

$3,300 HSA Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$3,300

$6,600

 

$6,400

$12,800

Out-of-Pocket Maximum

Individual

Family

 

$3,300

$6,600

 

$9,600

$19,200

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

0%*

0%*

0%*

 

50%*

50%*

50%*

Urgent Care Services

0%*

50%*

Complex Imaging: MRI/CT/PET Scans

0%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

0%*

0%*

50%*

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

0%*

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

0%*

0%*

0%*

0%*

Mail Order 90 Day Supply

0%*

0%*

0%*

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$5,000 HSA Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$5,000

$10,000

 

$10,000

$20,000

Out-of-Pocket Maximum

Individual

Family

 

$8,000

$16,000

 

$20,000

$40,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

25%*

25%*

25%*

 

50%*

50%*

50%*

Urgent Care Services

25%*

50%*

Complex Imaging: MRI/CT/PET Scans

25%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

25%*

25%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

25%*

25%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

25%*

25%*

50%*

25%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

25%*

25%*

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

25%*

25%*

25%*

25%*

Mail Order 90 Day Supply

25%*

25%*

25%*

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$2,500 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$2,500

$5,000

 

$5,000

$10,000

Out-of-Pocket Maximum

Individual

Family

 

$5,000

$10,000

 

$15,000

$30,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$45 Copay

$45 Copay

$45 Copay

 

50%*

50%*

50%*

Urgent Care Services

$45 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

25%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

25%*

25%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

25%*

25%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

25%*

25%*

50%*

25%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

25%*

$45 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

$12 Copay

$50 Copay

$90 Copay

20% Coinsurance up to $200

Mail Order 90 Day Supply

$24 Copay

$100 Copay

$180 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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