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P A G E 6
Plan Design
Traditional PPO Plan
Calvert Local Network
CareFirst Network
Plan Year Deductible
In-Network
Out-of-Network
Individual
$500
$1,000
$2,000
Emp+Spouse / Emp+Child(ren) / Family
$1,000
$2,000
$4,000
Out of Pocket Maximum (Medical)
Individual
$2,500
$3,000
$10,000
Emp+Spouse / Emp+Child(ren) / Family
$5,000
$6,000
$20,000
Preventive Care*
- Well Child Care
No charge
No charge
Not Covered
- Adult
No charge
No charge
Not Covered
- Cancer Screenings
No charge
No charge
Not Covered
Office Visits
Deductible, then:
Primary Care Physician
$20 co-pay
$30 co-pay
60% Allowed Benefit
Specialist
$30 co-pay
$40 co-pay
60% Allowed Benefit
Diagnostic Imaging & Lab Testing
Deductible, then:
Outpatient (free-standing)
Deductible, then 90%
Deductible, then 70%
60% Allowed Benefit
Hospitalization
Deductible, then:
Inpatient
100%
Deductible, then 70%
60% of Allowed Benefit
Outpatient
Deductible, then 90%
Deductible, then 70%
60% of Allowed Benefit
Emergency Room (waived if admitted)
$100 co-pay
$100 co-pay
$100 co-pay
Urgent Care
$50 co-pay
$50 co-pay
$50 co-pay
Prescription Drugs**
Out of Pocket Maximum (Rx)
$3,500 per Individual or $7,000 per Family
Generic Formulary
$10 co-pay
$10 co-pay
$10 co-pay
Brand Formulary
$35 co-pay
$35 co-pay
$35 co-pay
Non-Formulary
$60 co-pay
$60 co-pay
$60 co-pay
Retail 90 Program (Walgreens only)***
2.5 x retail co-pay or full cost; whichever is less expensive
Mail Order***
2.5 x retail co-pay or full cost; whichever is less expensive
What does it mean for the Calvert Medical Plan to be “Self-Funded”?
Having a self-funded plan means that the cost of
all claims
incurred under the medical and prescription plan by all
covered lives are paid directly by Calvert. Some advantages of a self-funded plan include the ability to offer innovative
and competitive health benefits specific to our participant’s needs. In addition, premiums are adjusted each year based
upon claims paid in the prior plan year instead of a flat premium increase as with a fully-funded medical plan.
NCAS is the provider that handles the claims administration for our self-funded medical plans.
Employees are being offered two different plans to choose from for the 2017/2018 Plan year.
Below you will see the Plan highlights for the Traditional PPO Plan.
*You cannot combine a preventive care visit with a visit to address any complaint/health issue. If you do so, the visit may not be coded as
a preventive visit and the visit may be subject to the annual deductible and/or co-pay. If during a preventive procedure, any other care or
diagnosis is determined, annual deductibles and co-pays may apply.
**Co-pays will be waived if you fill a prescription for generic maintenance medications, filled by mail order or at a Walgreens retail
pharmacy, for any of the five specified health conditions (asthma, diabetes, depression, hypertension, hyperlipidemia).
***Must be written as a 90-day supply.
Medical Benefits Description