Plan Details

Summary Of Medical Benefits

Copay Plan

In-Network

Out-Of-Network

Calendar Year Deductible

Individual

Family

$2,500

$5,000

$10,000

$20,000

Out-Of-Pocket Maximum

Individual

Family

$2,500

$10,000

$40,000

Preventive Care

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

$30 Copay

$50 Copay

0%*

40%*

Hospital Services

0%*

40%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

$250 Copay

0%*

40%*

Urgent Care Services

$45 Copay

40%*

Mental Health / Chemical Dependency

Inpatient

Outpatient

0%*

$30 Copay

40%*

Teladoc Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, initial evaluation

Mental Health - Psychiatrist, ongoing session

100% Covered

$85 Copay

100% Covered

$85 Copay

100% Covered

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$10 Copay

$40 Copay

$80 Copay

Not available

Mail Order 90 Day Supply

$25 Copay

$100 Copay

$200 Copay

Not Available

* Coinsurance After deductible

** True emergencies covered at in-network level

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

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