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P A G E 7
Plan Design
High Deductible Health Plan with HSA
Calvert Local Network
CareFirst Network
Plan Year Deductible
In-Network
Out-of-Network
Individual
$2,000
$2,000
$4,000
Emp+Spouse / Emp+Child(ren) / Family
$4,000
$4,000
$8,000
Out of Pocket Maximum
Individual
$5,000
$5,000
$10,000
Emp+Spouse / Emp+Child(ren) / Family
$10,000
$10,000
$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
Primary Care Physician
Deductible, then 90%
Deductible, then 90%
Deductible, then 70%
Specialist
Deductible, then 90%
Deductible, then 90%
Deductible, then 70%
Diagnostic Imaging & Lab Testing
Outpatient (free-standing)
Deductible, then 90%
Deductible, then 90%
Deductible, then 70%
Hospitalization
Inpatient
Deductible, then 90%
Deductible, then 90%
Deductible, then 70%
Outpatient
Deductible, then 90%
Deductible, then 90%
Deductible, then 70%
Emergency Room (waived if admitted)
Deductible, then 90%
Deductible, then 90%
Deductible, then 70%
Urgent Care
Deductible, then 90%
Deductible, then 90%
Deductible, then 70%
Prescription Drugs**
Deductible, then:
Deductible, then:
Generic Formulary
$10 co-pay
$10 co-pay
Brand Formulary
$35 co-pay
$35 co-pay
Non-Formulary
$60 co-pay
$60 co-pay
Retail 90 (Walgreens only)***
2.5 x retail cost of 30-day prescription or full cost; whichever is less expensive
Mail Order***
2.5 x retail cost of 30-day prescription or full cost; whichever is less expensive
Medical Benefits Description
NCAS is the provider that handles the claims administration for our self-funded medical plans.
Employees are being offered two different plans for the 2017/2018 Plan year. Below you will see
the plan highlights for the High Deductible Health Plan with a Health Savings Account feature.
*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 for specific preventive drugs. Refer to your benefit summary for a specific drug list. The cost of prescriptions will
apply towards the annual deductibles for the plan.
***Must be written as a 90-day supply.
Generic Prescriptions = Savings
Remember to ask your doctor for generic drugs when possible. A generic 30-day
prescription at a retail pharmacy is still just $10, after annual deductible has been met.