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

Option 1

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual under Family

Family

 

$5,000

$5,000

$10,000

 

$10,000

$10,000

$20,000

Out-of-Pocket Maximum

Individual

Individual under Family

Family

 

$6,350

$6,350

$12,700

 

$12,700

$12,700

$25,400

Preventative Services

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$20 Copay

$40 Copay

$40 Copay

 

40%*

40%*

40%*

Urgent Care Services

$75 Copay

40%*

Complex Imaging: MRI/CT/PET Scans

20%*

40%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Emergency Room Services

Emergency Medical Transportation

$200 Copay, then 20%*

20%*

$200 Copay, then 20%*

40%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$20 Copay

 

40%*

40%*

Teladoc Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, initial evaluation

Mental Health - Psychiatrist, ongoing session

 

No Charge

No Charge

No Charge

No Charge

No Charge

 

No Charge

No Charge

No Charge

No Charge

No Charge

NOTE: * Coinsurance after deductible

** Covered as in-network in true-emergency

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

 

 

 

 

 

 

Option 2

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual under Family

Family

 

$1,500

$1,500

$3,000

 

$3,000

$3,000

$6,000

Out-of-Pocket Maximum

Individual

Individual under Family

Family

 

$4,000

$4,000

$8,000

 

$8,000

$8,000

$16,000

Preventative Services

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$20 Copay

$40 Copay

$40 Copay

 

40%*

40%*

40%*

Urgent Care Services

$75 Copay

40%*

Complex Imaging: MRI/CT/PET Scans

20%*

40%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Emergency Room Services

Emergency Medical Transportation

$200 Copay, then 20%*

20%*

$200 Copay, then 20%*

40%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$20 Copay

 

40%*

40%*

Teladoc Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, initial evaluation

Mental Health - Psychiatrist, ongoing session

 

No Charge

No Charge

No Charge

No Charge

No Charge

 

No Charge

No Charge

No Charge

No Charge

No Charge

NOTE: * Coinsurance after deductible

** Covered as in-network in true-emergency

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

 

 

 

 

 

 

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