Plan Details

Summary of Medical Benefits

Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

$5,000

$10,000

$20,000

Out-of-Pocket Maximum

Individual

Family

$7,900

$15,800

$31,600

Preventative Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

$25 Copay

$75 Copay

$25 Copay

50%*

Urgent Care Services

$50 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

0%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

0%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

0%*

50%*

Emergency Room Services

Emergency Medical Transportation

$300 Copay

0%*

$300 Copay

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

0%*

$75 Copay

50%*

Teledoc Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

No Charge

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$15 Copay

$35 Copay

$75 Copay

$250 Copay

Mail Order 90 Day Supply

$37.50 Copay

$87.50 Copay

$187.50 Copay

Not Available

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

* Coinsurance after deductible

** Covered as in-network in true-emergency

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