Plan Details

Summary Of Medical Benefits

Copay Plan

In-Network

Out-Of-Network

Calendar Year Deductible

Individual

Family

$2,000

$4,000

N/A

Out-Of-Pocket Maximum

Individual

Family

$4,000

$8,000

N/A

Preventive Care

100% Covered

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

$30 Copay

$60 Copay

20%*

Not Covered

Urgent Care Services

$60 Copay

Not Covered

Complex Imaging: MRI/CT/PET Scans

$50 Copay

Not Covered

Inpatient Hospital Care

Facility Fee

Physician Fee

20%*

Not Covered

Outpatient Procedures

Facility Fee

Physician Fee

20%*

Not Covered

Emergency Room**

Emergency Medical Transportation

$500 Copay

20%*

Not Covered

Mental Health / Chemical Dependency

Inpatient

Outpatient

20%*

$60 Copay

Not Covered

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$10 Copay

$30 Copay

$75 Copay

$1,000 Copay

Mail Order 90 Day Supply

$20 Copay

$100 Copay

$200 Copay

Not Available

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatric, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

No Charge

$85 Copay

No Charge

$85 Copay

No Charge

* Coinsurance After deductible

** True emergencies covered at in-network level

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

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