Plan Details

Summary of Medical Benefits

Copay Plan

In-Network

Out-Of-Network

Deductible

Individual

Family

$6,000

$13,700

$10,000

$20,000

Out-Of-Pocket Maximum

Individual

Family

$6,000

$13,700

$12,000

$27,400

Preventive Care Services

No Charge

10%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

$50 Copay

$75 Copay

$50 Copay

10%*

Urgent Care Services

$150 Copay

10%*

Complex Imaging: MRI/CT/PET Scans

0%*

10%*

Inpatient Hospital Care

Facility Fee

Physician Fee

0%*

10%*

Outpatient Procedures

Facility Fee

Physician Fee

0%*

10%*

Emergency Room Services

Emergency Medical Transportation

$500 Copay, then 0%*

0%*

$500 Copay, then 0%*

10%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

0%*

$50 Copay

10%*

Prescription Drug Coverage

Generic

Preferred Brand

Brand Non-Formulary

Specialty Drugs

Retail 30 Day Supply

$5 Copay

$50 Copay

$100 Copay

$150 Copay

Mail Order 90 Day Supply

$10 Copay

$100 Copay

$200 Copay

$300 Copay

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

No Charge

NOTE: * Coinsurance After Deductible

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

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