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6
UNDERS TAND I NG
YOUR MEDICAL PLAN
BENEFIT
IN-NETWORK
OUT-OF-NETWORK
Individual
None
$1,000
Family
None
$2,000
Individual
$1,250
$4,000
Family
$3,750
$8,000
Lifetime Maximum Benefit
Unlimited
Unlimited
Primary Care Physician Office Visits
$20 co-pay per visit
Plan pays 80% after Deductible
Specialist Office Visits
$40 co-pay per visit
Plan pays 80% after Deductible
Urgent Care
$50 co-pay per visit
Plan pays 80% after Deductible
Emergency Room
$100 co-pay
(Waived if admitted)
$100 co-pay
(Waived if admitted)
Maternity Physician Services
$20 co-pay
(First office visit only)
Plan pays 80% after Deductible
Hospital Inpatient Expenses
$500 co-pay per inpatient stay
Plan pays 80% after Deductible
Hospital Outpatient Expenses
Plan pays 100%
Plan pays 80% after Deductible
Outpatient Therapies
(ex: physical, speech and occupational)
60 visit maximum per calendar year
$20 co-pay per visit Plan pays 80% after Deductible
Chiropractic Care
$20 co-pay per visit
Plan pays 80% after Deductible
Mental Health/Behavioral Treatment Services
Inpatient: $500 co-pay per stay
Outpatient: $20 co-pay per visit
Plan pays 80% after Deductible
Durable Medical Equipment
Limited to 1 type of DME (including repair/replacement) every 3 years
Plan pays 100%
Plan pays 80% after Deductible
(Pre-authorization required for charges
over $1,000)
Retail Pharmacy
(31 day supply)
$10 for Tier 1 drugs
$30 for Tier 2 drugs
$50 for Tier 3 drugs
$10 for Tier 1 drugs
$30 for Tier 2 drugs
$50 for Tier 3 drugs
Mail Order Maintenance Drug
(90 day supply)
$25 for Tier 1 drugs
$75 for Tier 2 drugs
$125 for Tier 3 drugs
Not Covered
Semi - Monthly Contributions
Pre Tax
Post Tax
Employee
$96.28
$0.00
Employee + 1
$185.44
$0.00
Family
$290.12
$0.00
Domestic Partner (DP)*
$0.00
$89.16
DP & DP Child(ren)*
$0.00
$193.84
*In addition to the post tax contributions, a portion of the premium for DP and dependents of DP will be taxable income to the employee. These amounts are $217.87 for DP
coverage only and $473.88 for DP and dependent coverage (per semi monthly pay period).
Prescription Drugs
CHOICE PLUS BUY UP PLAN
Annual Deductible
Annual Out of Pocket Maximum
(Includes all co-pays)