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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

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 Services

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%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

0%*

0%*

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

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 Out-of-Pocket Maximum

Individual

Family

 

$6,000

$6,000

 

$12,000

$12,000

Prescription Drug Coverage

Generic

Preferred Brand

Non-preferred brand

Specialty

Retail 30 Day Supply

Rx OOP, then 100% covered

Rx OOP, then 100% covered

Rx OOP, then 100% covered

Rx OOP, then 100% covered

Mail Order 90 day Supply

Rx OOP, then 100% covered

Rx OOP, then 100% covered

Rx OOP, then 100% covered

Not Available

NOTE: * Coinsurance After Deductible

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

 

 

 

 


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