Plan Details

Summary of Medical Benefits

Your healthcare coverage is important to us. Age, family status, medical conditions, hobbies, lifestyle and a myriad of other factors will help you determine if you need a lot or a very little amount of health coverage. This summary will help you understand your plan and its coverage.

Summary Of Medical Benefits

HSA Plan

In-Network

Out-Of-Network

Plan Year Deductible

Employee Only

Family

 

$3,200

$6,000

 

N/A

N/A

Coinsurance

20%

N/A

Out-Of-Pocket Maximum

Employee Only

Family

 

$4,000

$8,000

 

N/A

N/A

Preventive Care

100% Covered

No Coverage

Office Visits

Primary Services

Specialist Services

 

20%*

20%*

 

No Coverage

No Coverage

Hospital Services Inpatients & Outpatient Care

20%*

No Coverage

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

20%*

20%*

 

No Coverage

No Coverage

Urgent Care Services

20%*

No Coverage

Chiropractic Services

20%*

No Coverage

Mental Health/Chemical Dependency

Inpatient

Outpatient

 

20%*

20%*

 

No Coverage

No Coverage

Retail 30 Day Supply

Mail Order 90 day Supply

Prescription Drug Coverage

Generic

Formulary

Non-Formulary

Specialty

 

20%*

20%*

20%*

20% Coinsurance

 

No Coverage

No Coverage

No Coverage

20% Coinsurance

*After Deductible

 

 

**Covered as in-network in true emergency

 

 


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