Plan Details
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
Copay Plan
In-Network
Out-Of-Network
Plan Year Deductible
Employee Only
Family
$1,000
$2,000
$4,000
Coinsurance
20%
40%
Out-Of-Pocket Maximum
$5,250
$10,500
$10,000
$20,000
Preventive Care
100% covered
No coverage
Physician Services
$30 copay
40%*
Hospital Services- Inpatient & Outpatient Care
20%*
Emergency Services
Covered as In-Network during true emergency
$150 copay
Urgent Care Services
$50 copay
Chiropractic Services
Not Covered
Mental Health / Chemical Dependency
Inpatient
Outpatient
$30 Copay
Retail 30 Day Supply
Mail Order 90 day Supply
Prescription Drug Coverage
Generic
Preferred brand
Non-preferred brand
Specialty
$15 copay
$35 copay
$37.50 copay
$87.50 copay
$125 copay
Not Available
NOTE: *After Deductible
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