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.

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Summary Of Medical Benefits

HSA Plan

In-Network

Out-Of-Network

Plan Year Deductible

Individual

Family

 

$3,300

$6,000

 

N/A

N/A

Out-Of-Pocket Maximum

Individual

Family

 

$4,000

$8,000

 

N/A

N/A

Preventive Care

No Charge

No Coverage

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

20%*

20%*

20%*

 

No Coverage

No Coverage

No Coverage

Urgent Care Services

20%*

No Coverage

Complex Imaging: MRI/CT/PET Scans

20%*

No Coverage

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

No Coverage

No Coverage

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

No Coverage

No Coverage

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

20%*

20%*

 

No Coverage

No Coverage

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

20%*

 

No Coverage

No Coverage

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

20% Coinsurance

20% Coinsurance

20% Coinsurance

20% Coinsurance

Mail Order 90 day Supply

No Coverage

No Coverage

No Coverage

20%*

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

100% Covered

100% Covered

100% Covered

100% Covered

100% Covered

 

100% Covered

100% Covered

100% Covered

100% Covered

100% Covered

NOTE: * Coinsurance After Deductible

**Covered as in-network in true emergency

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

 

 

 

 

 

 


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