Compare Plans

Not all coverage is the right coverage.

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 Eligible HDHP Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$5,000

$10,000

 

N/A

N/A

Out-of-Pocket Maximum

Individual

Family

 

$6,000

$12,000

 

N/A

N/A

Preventive Care Services

No Charge

No Coverage

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

0%*

0%*

0%*

 

No Coverage

No Coverage

No Coverage

Urgent Care Services

0%*

No Coverage

Complex Imaging: MRI/CT/PET Scans

0%*

No Coverage

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

No Coverage

No Coverage

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

No Coverage

No Coverage

Emergency Room

Emergency Medical Transportation

0%*

0%*

0%*

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

0%*

 

No Coverage

No Coverage

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$10 Copay After Deductible

$35 Copay After Deductible

$60 Copay After Deductible

$150 Copay After Deductible

Mail Order 90 Day Supply

$25 Copay After Deductible

$88 Copay After Deductible

$150 Copay After Deductible

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

Buy-Up Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$1,500

$3,000

 

N/A

N/A

Out-of-Pocket Maximum

Individual

Family

 

$3,000

$6,000

 

N/A

N/A

Preventive Care Services

No Charge

No Coverage

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay

$50 Copay

$50 Copay

 

No Coverage

No Coverage

No Coverage

Urgent Care Services

$75 Copay

No Coverage

Complex Imaging: MRI/CT/PET Scans

0%*

No Coverage

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

No Coverage

No Coverage

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

No Coverage

No Coverage

Emergency Room

Emergency Medical Transportation

$300 Copay (Copay waived if admitted)

0%*

$300 Copay (Copay waived if admitted)

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

$50 Copay

 

No Coverage

No Coverage

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$10 Copay

$40 Copay

$75 Copay

$150 Copay

Mail Order 90 Day Supply

$38 Copay

$100 Copay

$150 Copay

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$2,000

$4,000

 

$5,000

$10,000

Out-of-Pocket Maximum

Individual

Family

 

$7,150

$14,300

 

$10,000

$20,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$10 Copay

$80 Copay

$80 Copay

 

50%*

50%*

50%*

Urgent Care Services

$25 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

$500 scan per day Copay

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

$300 Copay (waived if admitted)

20%*

$300 Copay (waived if admitted)

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$80 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$15 Copay

$40 Copay

$75 Copay

$150 Copay

Mail Order 90 Day Supply

$38 Copay

$100 Copay

$175 Copay

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

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