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

$3,000 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$3,000

$6,000

 

N/A

N/A

Out-of-Pocket Maximum

Individual

Family

 

$6,500

$13,000

 

N/A

N/A

Preventive Care Services

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay

$75 Copay

$25 Copay

 

Not Covered

Not Covered

Not Covered

Urgent Care Services

$50 Copay

Not Covered

Complex Imaging: MRI/CT/PET Scans

20%*

Not Covered

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

Not Covered

Not Covered

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

Not Covered

Not Covered

Emergency Room Services

Emergency Medical Transportation

$300 Copay, then 20%*

20%*

$300 Copay, then 20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$75 Copay

 

Not Covered

Not Covered

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

$10 Copay

$35 Copay

$75 Copay

$250 Copay

Mail Order 90 Day Supply

$25 Copay

$87.50 Copay

$187.50 Copay

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$5,000 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$5,000

$10,000

 

N/A

N/A

Out-of-Pocket Maximum

Individual

Family

 

$8,150

$16,300

 

N/A

N/A

Preventive Care Services

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay

$75 Copay

$25 Copay

 

Not Covered

Not Covered

Not Covered

Urgent Care Services

$50 Copay

Not Covered

Complex Imaging: MRI/CT/PET Scans

20%*

Not Covered

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

Not Covered

Not Covered

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

Not Covered

Not Covered

Emergency Room Services

Emergency Medical Transportation

$300 Copay, then 20%*

20%*

$300 Copay, then 20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$75 Copay

 

Not Covered

Not Covered

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

$10 Copay

$35 Copay

$75 Copay

$250 Copay

Mail Order 90 Day Supply

$25 Copay

$87.50 Copay

$187.50 Copay

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$5,000 HSA Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$5,000

$10,000

 

N/A

N/A

Out-of-Pocket Maximum

Individual

Family

 

$6,900

$13,800

 

N/A

N/A

Preventive Care Services

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay After Deductible

$75 Copay After Deductible

0%*

 

Not Covered

Not Covered

Not Covered

Urgent Care Services

$50 Copay After Deductible

Not Covered

Complex Imaging: MRI/CT/PET Scans

0%*

Not Covered

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

Not Covered

Not Covered

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

Not Covered

Not Covered

Emergency Room Services

Emergency Medical Transportation

$300 Copay After Deductible

0%*

$300 Copay After Deductible

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

$75 Copay After Deductible

 

Not Covered

Not Covered

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

$10 Copay After Deductible

$35 Copay After Deductible

$75 Copay After Deductible

$250 Copay After Deductible

Mail Order 90 Day Supply

$25 Copay After Deductible

$87.50 Copay After Deductible

$187.50 Copay After Deductible

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

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