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

$2,000 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$2,000

$6,000

 

$6,000

$18,000

Out-of-Pocket Maximum

Individual

Family

 

$7,900

$15,800

 

$23,700

$47,400

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$30 Copay

$50 Copay

$30 Copay

 

50%*

50%*

50%*

Urgent Care Services

$75 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

0%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

$350 Copay

0%*

$350 Copay

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

$30 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$15 Copay

$45 Copay after Deductible

$85 Copay after Deductible

25% Coinsurance up to $350 per prescription after RX Deductible

Mail Order 90 Day Supply

$15 Copay

$90 Copay after Deductible

$225 Copay after Deductible

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$3,500 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$3,500

$10,500

 

$10,500

$31,000

Out-of-Pocket Maximum

Individual

Family

 

$7,900

$15,800

 

$23,700

$47,400

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$30 Copay

$50 Copay

$30 Copay

 

50%*

50%*

50%*

Urgent Care Services

$75 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

0%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

$350 Copay

0%*

$350 Copay

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

$30 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$15 Copay

$45 Copay after Deductible

$85 Copay after Deductible

25% Coinsurance up to $350 per prescription after RX Deductible

Mail Order 90 Day Supply

$15 Copay

$90 Copay after Deductible

$225 Copay after Deductible

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

 

$10,000

$20,000

Out-of-Pocket Maximum

Individual

Family

 

$9,100

$18,200

 

$23,700

$47,400

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$45 Copay

$60 Copay

$45 Copay

 

50%*

50%*

50%*

Urgent Care Services

$75 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

0%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

0%*

0%*

0%*

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

$45 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$15 Copay

50%*

50%*

50%*

Mail Order 90 Day Supply

$30 Copay

50%*

50%*

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

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