Plan Details

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

HSA Plan Details

In-Network

Out-Of-Network

Deductible

Individual

Family

 

$3,400

$6,400

 

Not Covered

Not Covered

Out-Of-Pocket Maximum

Individual

Family

 

$7,000

$14,000

 

Not Covered

Not Covered

Preventive Care

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

20%*

20%*

20%*

 

Not Covered

Not Covered

Not Covered

Urgent Care Services

20%*

Not Covered

Hospital Services

Faciliy Fee

Physician Fee

 

20%*

20%*

 

Not Covered

Not Covered

Outpatient Procedures

Faciliy Fee

Physician Fee

 

20%*

20%*

 

Not Covered

Not Covered

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

20%*

20%*

 

Not Covered

Not Covered

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

20%*

 

Not Covered

Not Covered

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

20%*

20%*

20%*

20%*

Mail Order 90 day Supply

20%*

20%*

20%*

Not Available

NOTE: * 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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