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Summary Of Medical Benefits

Copay Plan

In-Network

Out-Of-Network

Calendar Year Deductible

Employee Only

Family

 

$2,000

$4,000

 

Not Covered

Not Covered

Out-Of-Pocket Maximum

Employee Only

Family

 

$5,000

$10,000

 

Not Covered

Not Covered

Preventive Care

No Charge

Not Covered

Office Visits

Primary Services

Specialist Services

Chiropractic Visit

 

$20 Copay

$40 Copay

10%*

 

Not Covered

Not Covered

Not Covered

Urgent Care Services

$50 Copay

Not Covered

Complex Imaging: MRI/CT/PET Scans

10%*

10%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

10%*

10%*

 

Not Covered

Not Covered

Outpatient Procedures

Facility Fee

Physician Fee

 

10%*

10%*

 

Not Covered

Not Covered

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

$500 Copay

10%*

Not Covered

$500 Copay

10%*

Mental Health / Chemical Dependency

Inpatient

Outpatient

 

10%*

$40 Copay

 

Not Covered

Not Covered

HealthiestYou Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

100% Covered

$70 Copay

100% Covered

100% Covered

100% Covered

 

100% Covered

$70 Copay

100% Covered

100% Covered

100% Covered

RX Deductible

Individual

Family

 

$100

$300

 

$100

$300

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$10 Copay

$20 Copay

$50 Copay

$1,000 Copay

Mail Order 90 day Supply

$20 Copay

$60 Copay

$150 Copay

Not Available

* After deductible

 

 

** True emergencies covered at in-network level

 

 


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