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

$9,100

$18,200

$15,000

$30,000

Preventive Care

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

$25 Copay

$50 Copay

$25 Copay*

50%*

Urgent Care Services

$50 Copay

50%*

Hospital Services Inpatient & Outpatient

0%*

50%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

$500 Copay*

0%*

50%*

Mental Health / Chemical Dependency

Inpatient

Outpatient

0%*

$50 Copay

50%*

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$10 Copay

$35 Copay

$75 Copay

Not Covered

Mail Order 90 day Supply

$20 Copay

$70 Copay

$150 Copay

Not Covered

Teladoc Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, initial evaluation

Mental Health - Psychiatrist, ongoing session

100% Covered

NOTE: * 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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