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.


Summary of Medical Benefits

$2,000 Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$2,000

$4,000

 

$4,000

$8,000

Out-of-Pocket Maximum

Individual

Family

 

$7,000

$14,000

 

$14,000

$28,000

Preventive Care Services

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$30 Copay

$60 Copay

$60 Copay

 

40%*

40%*

40%*

Urgent Care Services

$75 Copay

40%*

Complex Imaging: MRI/CT/PET Scans

20%*

40%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Emergency Room

Facility Fee

Physician Fee

Emergency Medical Transportation

 

$500 Copay

No Charge

20%*

 

$500 Copay

No Charge

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$30 Copay

 

40%*

40%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

No Charge

$25 Copay

$50 Copay

$100 Copay

Mail Order 90 Day Supply

No Charge

$65 Copay

$125 Copay

Not Available

Teladoc Services

General Consultations

Dermatology

Therapist

Psychiatrist - Initial Evaluation

Psychiatrist - Ongoing Evaluation

 

No Charge

No Charge

No Charge

No Charge

No Charge

 

No Charge

No Charge

No Charge

No Charge

No Charge

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$4,000 Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$4,000

$8,000

 

$8,000

$16,000

Out-of-Pocket Maximum

Individual

Family

 

$9,000

$16,000

 

$14,000

$28,000

Preventive Care Services

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$30 Copay

$60 Copay

$60 Copay

 

40%*

40%*

40%*

Urgent Care Services

$75 Copay

40%*

Complex Imaging: MRI/CT/PET Scans

20%*

40%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Emergency Room

Facility Fee

Physician Fee

Emergency Medical Transportation

 

$500 Copay

No Charge

20%*

 

$500 Copay

No Charge

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$30 Copay

 

40%*

40%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

No Charge

$25 Copay

$50 Copay

$100 Copay

Mail Order 90 Day Supply

No Charge

$65 Copay

$125 Copay

Not Available

Teladoc Services

General Consultations

Dermatology

Therapist

Psychiatrist - Initial Evaluation

Psychiatrist - Ongoing Evaluation

 

No Charge

No Charge

No Charge

No Charge

No Charge

 

No Charge

No Charge

No Charge

No Charge

No Charge

NOTE: * Coinsurance After Deductible

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

 

 

 

 


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