Summary of Medical Benefits
PPO 1 Plan
In-Network
Out-of-Network
|
Calendar Year Accumulation Embedded Deductible Employee only Family |
$0 $0 |
$2,000 $4,000 |
|
Coinsurance |
0% |
25% |
|
Embedded Out-of-Pocket Maximum Employee only Family |
$5,000 $10,000 |
$5,000 $10,000 |
|
Recuro Telemedicine Services |
100% Covered |
100% Covered |
|
Preventive Care |
100% Covered |
50% Coinsurance |
|
Office Visits Primary Services Specialist Services Walk In Clinics Chiropractic Services |
$20 Copay $50 Copay $40 Copay 25% Coinsurance |
25%* After Deductible 25%* After Deductible 25%* After Deductible 50%* After Deductible |
|
Urgent Care Services |
$40 Copay |
25%* After Deductible |
|
Emergency Services Emergency Room Emergency Medical Transportation |
$200 Copay 0%* After Deductible |
$200 Copay 0%* After Deductible |
|
Hospital Services Inpatient Hospital Facility Outpatient Surgery |
$250 Copay / Day (5 Days Max) $500 Copay |
25%* After Deductible 25%* After Deductible |
|
Diagnostic Testing & Imaging Labs X-rays CT/PET/MRI |
$40 Copay $60 Copay $200 Copay |
25%* After Deductible 25%* After Deductible 25%* After Deductible |
|
Mental Health/Chemical Dependency Inpatient Outpatient |
0%* After Deductible $50 Copay |
25%* After Deductible 25%* After Deductible |
|
Prescription Drug Coverage Generic Preferred brand Non-preferred brand Specialty |
Retail 30 Day Supply $10 Copay $25 Copay $75 Copay $150 Copay |
Mail Order 90 Day Supply $20 Copay $50 Copay $150 Copay Not Available |
|
* Coinsurance Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions An Embedded Deductible means that each individual will only have to meet the individual Deductible before the Plan begins paying benefits for such individual that are subject to a Deductible An Embedded Out-of-Pocket Maximum means that each individual will only have to meet the individual out-of-pocket maximum before the Plan begins paying in full for such individual. |
|
|
PPO 4 Plan
In-Network
Out-of-Network
|
Calendar Year Accumulation Embedded Deductible Employee only Family |
$2,000 $4,000 |
$4,000 $8,000 |
|
Embedded Out-of-Pocket Maximum Employee only Family |
$6,000 $12,000 |
$12,000 $24,000 |
|
Recuro Telemedicine Services |
100% Covered |
100% Covered |
|
Preventive Care |
100% Covered |
50% Coinsurance |
|
Office Visits Primary Services Specialist Services Chiropractic Services |
$20 Copay $75 Copay 25% Coinsurance* |
50% Coinsurance* 50% Coinsurance* 50% Coinsurance* |
|
Urgent Care Services |
$50 Copay |
50% Coinsurance* |
|
Emergency Services Emergency Room** Emergency Medical Transportation** |
$300 Copay* 0% Coinsurance* |
$300 Copay* 0% Coinsurance* |
|
Inpatient Hospital Services Facility Fee Physician Fee |
0% Coinsurance* 0% Coinsurance* |
50% Coinsurance* 50% Coinsurance* |
|
Outpatient Procedures Facility Fee Physician Fee |
$750 Copay* 0% Coinsurance* |
50% Coinsurance* 50% Coinsurance* |
|
Mental Health/Chemical Dependency Inpatient Outpatient |
0% Coinsurance $20 Copay |
50% Coinsurance* 50% Coinsurance* |
|
Prescription Drug Coverage Generic Preferred brand Non-preferred brand Specialty |
Retail 30 Day Supply $10 Copay $25 Copay 50% Coinsurance $200 Copay |
Mail Order 90 Day Supply $20 Copay $50 Copay 50% Coinsurance Not Available |
|
* After Deductible Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions An Embedded Deductible means that each individual will only have to meet the individual Deductible before the Plan begins paying benefits for such individual that are subject to a Deductible An Embedded Out-of-Pocket Maximum means that each individual will only have to meet the individual out-of-pocket maximum before the Plan begins paying in full for such individual. |
|
|
HDHP 4
In-Network
Out-of-Network
|
Calendar Year Accumulation Embedded Deductible Employee only Family |
$5,000 $10,000 |
$10,000 $20,000 |
|
Coinsurance |
20% |
50% |
|
Embedded Out-of-Pocket Maximum Employee only Family |
$6,750 $13,500 |
$15,000 $30,000 |
|
Recuro Telemedicine Services |
100% Covered |
100% Covered |
|
Preventive Care |
100% Covered |
50%* After Deductible |
|
Office Visits Primary Services Specialist Services Walk In Clinics Chiropractic Services |
20%* After Deductible 20%* After Deductible 20%* After Deductible 20%* After Deductible |
50%* After Deductible 50%* After Deductible 50%* After Deductible 50%* After Deductible |
|
Urgent Care Services |
20%* After Deductible |
50%* After Deductible |
|
Emergency Services Emergency Room Emergency Medical Transportation |
20%* After Deductible 20%* After Deductible |
20%* After Deductible 20%* After Deductible |
|
Hospital Services Inpatient Hospital Facility Outpatient Surgery |
20%* After Deductible 20%* After Deductible |
50%* After Deductible 50%* After Deductible |
|
Diagnostic Testing & Imaging Labs X-rays CT/PET/MRI |
20%* After Deductible 20%* After Deductible 20%* After Deductible |
50%* After Deductible 50%* After Deductible 50%* After Deductible |
|
Mental Health/Chemical Dependency Inpatient Outpatient |
20%* After Deductible 20%* After Deductible |
50%* After Deductible 50%* After Deductible |
|
Prescription Drug Coverage Generic Preferred brand Non-preferred brand Specialty |
Retail 30 Day Supply 20%* After Deductible 20%* After Deductible 50%* After Deductible 20%* After Deductible |
Mail Order 90 Day Supply 20%* After Deductible 20%* After Deductible 50%* After Deductible Not Available |
|
*Coinsurance Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions An Embedded Deductible means that each individual will only have to meet the individual Deductible before the Plan begins paying benefits for such individual that are subject to Deductible An Embedded Out-of-Pocket Maximum means that each individual will only have to meet the individual out-of-pocket maximum before the Plan begins paying in full for such individual |
|
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If you prefer talking with a HealthEZ representative, call 855-255-7060