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

Individual under Family

Family

 

$7,000

$7,000

$14,000

 

N/A

N/A

N/A

Embedded Out-of-Pocket Maximum

Individual

Individual under Family

Family

 

$8,000

$8,000

$16,000

 

N/A

N/A

N/A

Preventative Services

No Charge

Not covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$30 Copay

$60 Copay

$60 Copay

 

Not covered

Not covered

Not covered

Urgent Care Services

$75 Copay

Not covered

Complex Imaging: MRI/CT/PET Scans

0%*

Not covered

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

Not covered

Not covered

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

Not covered

Not covered

Emergency Room Services**

Emergency Medical Transportation**

$350 Copay

0%*

Not covered

Not covered

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

0%*

 

Not covered

Not covered

Teladoc Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

Prescription Drug Coverage

Preventative

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

 

$10 Copay

$50 Copay

$85 Copay

$250 Copay

Mail Order 90 Day Supply

 

$20 Copay

$100 Copay

$164 Copay

Not Available

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

* Coinsurance after deductible

** Covered as in-network in true-emergency

 

 

 

 

 

 

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