Plan Details

Summary of Medical Benefits

Copay Plan 1

In-Network

Out-of-Network

Deductible

Individual

Family

$5,000

$10,000

$5,000

$15,000

Out-of-Pocket Maximum

Individual

Family

$5,500

$11,000

$10,000

$20,000

Preventive Care Services

No Charge

20%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

$35 Copay

$70 Copay

0%*

20%*

Urgent Care Services

0%*

20%*

Complex Imaging: MRI/CT/PET Scans

0%*

20%*

Inpatient Hospital Care

Facility Fee

Physician Fee

0%*

20%*

Outpatient Procedures

Facility Fee

Physician Fee

0%*

20%*

Emergency Room

Emergency Medical Transportation

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

0%*

$35 Copay

20%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$15 Copay

$50 Copay

$100 Copay

Mail Order 90 Day Supply

$37.50 Copay

$125 Copay

$250 Copay

Not Covered

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental HEalth - Psychiatrist, Ongoing Session

No Charge

NOTE: * Coinsurance After Deductible

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

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