Plan Details

Summary Of Medical Benefits

PPO Plan

In-Network

Out-Of-Network

Embedded Plan Year Deductible

Individual

Family

$1,000

$2,000

$1,500

$3,500

Embedded Out-Of-Pocket Maximum

Individual

Family

$1,500

$3,500

$2,500

$6,500

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

$25 Copay

20%*

35%*

Urgent Care Services

$50 Copay per visit, then 20% Coinsurance

Complex Imaging: MRI/CT/PET Scans

No Charge

35%*

Inpatient Hospital Care

Facility Fee

Physician Fee

$250 Copay, then 20%*

20%*

35%*

Outpatient Procedures

Facility Fee

Physician Fee

20%*

35%*

Emergency Room Services

Emergency Medical Transportation

$50 Copay, then 20% Coinsurance

20%*

$50 Copay, then 20% Coinsurance

35%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

Not Covered

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

No Charge

Summary of Pharmacy Benefits

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$20 Copay

$40 Copay

$60 Copay

$80 Copay

Mail Order 90 Day Supply

$60 Copay

$120 Copay

$180 Copay

Not Available

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

* Coinsurance after deductible

** Covered as in-network in true-emergency

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