Summary Of Medical Benefits
Medical Plan
In-Network
Out-Of-Network
Calendar Year Deductible Individual Family |
$6,000 $12,000 |
$12,000 $24,000 |
Out-Of-Pocket Maximum Individual Family |
$6,000 $12,000 |
$12,000 $24,000 |
Preventive Care |
No Charge |
No Charge |
Office Visits Primary Office Visit Specialist Office Visit Chiropractic Visit |
0%* 0%* 0%* |
0%* 0%* 0%* |
Urgent Care Services |
0%* |
0%* |
Complex Imaging: MRI/CT/PET Scans |
0%* |
0%* |
Hospital Services |
0%* |
0%* |
Emergency Services Emergency Room Emergency Medical Transportation |
0%* 0%* |
0%* 0%* |
Mental Health/Chemical Dependency Inpatient Office Visit |
0%* 0%* |
0%* 0%* |
Prescription Drug Coverage Generic Preferred brand Non-preferred brand Specialty |
Retail 30 Day Supply 0%* 0%* 0%* 0%* |
Mail Order 90 day Supply 0%* 0%* 0%* Not Available |
* Coinsurance After Deductible Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions |
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