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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

Copay Plan 1 - Effective 1/1/2023

In-Network

Out-Of-Network

Calendar Year Deductible

Employee Only

Family

 

$5,000

$10,000

 

$10,000

$20,000

Coinsurance

30%*

50%*

Medical Out-Of-Pocket Maximum

Employee Only

Family

 

$5,600

$10,200

 

$20,000

$60,000

Preventive Care

100% Covered

30%*

Office Visits

Primary Services

Specialist Services

Office Visit, Labs, Pathology, Ultrasound and X-Ray

 

$40 Copay

$40 Copay

100% Covered

 

30%*

30%*

30%*

Hospital Services

Inpatient Services

Complex Imagine: MRI/CT/PET Scans

Hospital Labs, Pathology, Ultrasound and X-Ray

 

30%*

30%*

100% Covered

 

50%*

30%*

30%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

$100 Copay, then 30%*

30%*

 

$100 Copay, then 50%*

50%*

Urgent Care Services

$65 Copay

30%*

Teladoc Services

General Consultations

Dermatology

 

100% Covered

$85 Copay

 

100% Covered

$85 Copay

Chiropractic Services

30%*

50%*

Mental Health / Chemical Dependency

Inpatient

Office Visit

 

30%*

$40 Copay

 

50%*

50%*

Prescription Out-of-Pocket Maximum

Employee Only

Family

 

Retail 30 Day Supply

$1,000

$3,000

 

Mail Order 90 day Supply

$1,000

$3,000

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

$20 Copay

$40 Copay

$60 Copay

$20/$40/$60 Copay

 

$40 Copay

$80 Copay

$120 Copay

Not Available

*After Deducible

 

 

** True emergencies covered at in-network level

 

 

Copay Plan 2 - Effective 1/1/2023

In-Network

Out-Of-Network

Calendar Year Deductible

Employee Only

Family

 

$5,000

$10,000

 

$10,000

$20,000

Coinsurance

30%*

50%*

Medical Out-Of-Pocket Maximum

Employee Only

Family

 

$5,600

$10,200

 

$20,000

$60,000

Preventive Care

100% Covered

30%*

Office Visits

Primary Services

Specialist Services

Office Visit, Labs, Pathology, Ultrasound and X-Ray

 

$40 Copay

$40 Copay

100% Covered

 

30%*

30%*

30%*

Hospital Services

Inpatient Services

Complex Imagine: MRI/CT/PET Scans

Hospital Labs, Pathology, Ultrasound and X-Ray

 

30%*

30%*

30%*

 

50%*

50%*

50%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

$100 Copay, then 30%*

30%*

 

$100 Copay, then 50%*

50%*

Urgent Care Services

$65 Copay

30%*

Teladoc Services

General Consultations

Dermatology

 

100% Covered

$85 Copay

 

100% Covered

$85 Copay

Chiropractic Services

30%*

50%*

Mental Health / Chemical Dependency

Inpatient

Office Visit

 

30%*

$40 Copay

 

50%*

50%*

Prescription Out-of-Pocket Maximum

Employee Only

Family

 

Retail 30 Day Supply

$1,000

$3,000

 

Mail Order 90 day Supply

$1,000

$3,000

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

$20 Copay

$40 Copay

$60 Copay

$20/$40/$60 Copay

 

$40 Copay

$80 Copay

$120 Copay

Not Available

*After Deducible

 

 

** True emergencies covered at in-network level

 

 

Copay Plan 3 - Effective 1/1/2023

In-Network

Out-Of-Network

Calendar Year Deductible

Employee Only

Family

 

$1,500

$4,500

 

$3,000

$9,000

Coinsurance

20%*

40%*

Medical Out-Of-Pocket Maximum

Employee Only

Family

 

$4,500

$10,200

 

$9,000

$27,000

Preventive Care

100% Covered

40%*

Office Visits

Primary Services

Specialist Services

Office Visit, Labs, Pathology, Ultrasound and X-Ray

 

$30 Copay

$30 Copay

100% Covered

 

40%*

40%*

40%*

Hospital Services

Inpatient Services

Complex Imagine: MRI/CT/PET Scans

Hospital Labs, Pathology, Ultrasound and X-Ray

 

20%*

20%*

100% Covered

 

40%*

40%*

40%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

$100 Copay, then 20%*

20%*

 

$100 Copay, then 40%*

40%*

Urgent Care Services

$55 Copay

40%*

Teladoc Services

General Consultations

Dermatology

 

100% Covered

$85 Copay

 

100% Covered

$85 Copay

Chiropractic Services

20%*

40%*

Mental Health / Chemical Dependency

Inpatient

Office Visit

 

20%*

$30 Copay

 

40%*

40%*

Prescription Out-of-Pocket Maximum

Employee Only

Family

 

Retail 30 Day Supply

$1,000

$3,000

 

Mail Order 90 day Supply

$1,000

$3,000

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

$20 Copay

$35 Copay

$50 Copay

$20/$35/$50 Copay

 

$40 Copay

$70 Copay

$100 Copay

Not Available

*After Deducible

 

 

** True emergencies covered at in-network level

 

 

HSA Plan - Effective 1/1/2023

In-Network

Out-Of-Network

Calendar Year Deductible

Employee Only

Family

 

$5,000

$10,000

 

$10,000

$20,000

Coinsurance

N/A

30%*

Medical Out-Of-Pocket Maximum

Employee Only

Family

 

$5,000

$10,000

 

Unlimited

Unlimited

Preventive Care

100% Covered

30%*

Office Visits

Primary Services

Specialist Services

Office Visit, Labs, Pathology, Ultrasound and X-Ray

 

No Charge*

No Charge*

No Charge*

 

30%*

30%*

30%*

Hospital Services

Inpatient Services

Complex Imagine: MRI/CT/PET Scans

Hospital Labs, Pathology, Ultrasound and X-Ray

 

No Charge*

No Charge*

No Charge*

 

30%*

30%*

30%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

No Charge*

No Charge*

 

30%*

30%*

Urgent Care Services

No Charge*

30%*

Teladoc Services

General Consulatations

Dermatology

 

100% Covered

$85 Copay*

 

100% Covered

$85 Copay*

Chiropractic Services

No Charge*

30%*

Mental Health / Chemical Dependency

Inpatient

Office Visit

 

No Charge*

No Charge*

 

30%*

30%*

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

No Charge*

No Charge*

No Charge*

No Charge*

 

 

No Charge*

No Charge*

No Charge*

Not Available

 

*After Deducible

 

 

** True emergencies covered at in-network level

 

 


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