Plan Details
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
HSA Plan
In-Network
Out-Of-Network
Calendar Year Deductible
Individual
Individual Under Family Coverage
Family
$2,000
$3,200
$4,000
$8,000
Coinsurance
20%
40%
Out-Of-Pocket Maximum
Employee Only
$16,000
Preventive Care
100% Covered
40%*
Office Visits
Primary Services
Specialist Services
Chiropractic Services
20%*
Hospital Services
Emergency Services**
Emergency Room
Emergency Medical Transportation
Urgent Care Services
Mental Health / Chemical Dependency
Inpatient
Outpatient
Retail 30 Day Supply
Mail Order 90 day Supply
Prescription Drug Coverage
Generic
Preferred brand
Non-preferred brand
Specialty
$15 Copay*
$30 Copay*
$60 Copay*
$45 Copay*
$90 Copay*
$180 Copay*
Not Available
* After deductible
** True emergencies covered at in-network level
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