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

PPO Copay Plan

In-Network

Out-Of-Network

Deductible

Individual

Family

 

$1,000

$2,000

 

$3,000

$6,000

Out-Of-Pocket Maximum

Individual

Family

 

$3,000

$6,000

 

$6,000

$12,000

Preventive Care Services

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$20 Copay

$30 Copay

20%*

 

50%*

50%*

50%*

Urgent Care Services

$30 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

20%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

50%*

50%*

Emergency Room Services

Emergency Medical Transportation

$300 Copay

20%*

50%*

50%*

Mental health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$20 copay

 

50%*

50%*

Retail 30 Day Supply

Mail Order 90 day Supply

Pharmacy Deductible per Individual

$50

$50

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

$15 copay

$30 copay

$50 copay

20%*

 

$30 copay

$60 copay

$100 copay

Not Available

NOTE: * Coinsurance After Deductible

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

 

 

 

 


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