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

$500 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$500

$1,000

 

$1,000

$2,000

Out-of-Pocket Maximum

Individual

Family

 

$3,000

$6,000

 

$6,000

$12,000

Preventive Care Services

No Charge

20%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$30 Copay

$60 Copay

$30 Copay

 

20%*

20%*

20%*

Urgent Care Services

$75 Copay

20%*

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

Emergency Medical Transportation

$350 Copay

20%*

$350 Copay

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$60 Copay

 

40%*

20%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$10 Copay

$30 Copay

$50 Copay

$150 Copay

Mail Order 90 Day Supply

$25 Copay

$75 Copay

$125 Copay

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$2,000 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$2,000

$4,000

 

$5,000

$10,000

Out-of-Pocket Maximum

Individual

Family

 

$4,000

$8,000

 

$15,000

$30,000

Preventive Care Services

No Charge

20%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$20 Copay

$20 Copay

$20 Copay

 

20%*

20%*

20%*

Urgent Care Services

$20 Copay

20%*

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

Emergency Medical Transportation

20%*

20%*

20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$20 Copay

 

40%*

20%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$10 Copay

$30 Copay

$50 Copay

$150 Copay

Mail Order 90 Day Supply

$25 Copay

$75 Copay

$125 Copay

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$3,300 HSA Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$3,300

$6,600

 

$10,000

$20,000

Out-of-Pocket Maximum

Individual

Family

 

$7,350

$14,700

 

$15,000

$30,000

Preventive Care Services

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

10%*

10%*

10%*

 

40%*

40%*

40%*

Urgent Care Services

10%*

40%*

Complex Imaging: MRI/CT/PET Scans

10%*

40%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

10%*

10%*

 

40%*

40%*

Outpatient Procedures

Facility Fee

Physician Fee

 

10%*

10%*

 

40%*

40%*

Emergency Room

Emergency Medical Transportation

10%*

10%*

10%*

10%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

10%*

10%*

 

40%*

40%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

10%*

10%*

10%*

10%*

Mail Order 90 Day Supply

10%*

10%*

10%*

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$6,700 HSA Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$6,700

$13,400

 

$13,400

$26,800

Out-of-Pocket Maximum

Individual

Family

 

$6,700

$13,400

 

$26,800

$53,600

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

0%*

0%*

0%*

 

50%*

50%*

50%*

Urgent Care Services

0%*

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%*

0%*

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

0%*

0%*

0%*

0%*

Mail Order 90 Day Supply

0%*

0%*

0%*

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

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