Plan Details

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HDHP 2

In-Network

Out-of-Network

Calendar Year Accumulation

Non-Embedded Deductible

Employee only

Family

$2,000

$4,000

$8,000

Non-Embedded Out-of-Pocket Maximum

Employee only

Family

$5,000

$10,000

$20,000

Recuro Telemedicine Services

100% Covered

Preventive Care

100% Covered

50% Coinsurance

Office Visits

Primary Services

Specialist Services

Chiropractic Services

Urgent Care Services

$30 Copay*

$75 Copay*

$50 Copay*

25%* After Deductible

CT/PET/MRI

$300 Copay*

25%* After Deductible

Emergency Services

Emergency Room

Emergency Medical Transportation

$300 Copay*

0%* After Deductible

$300 Copay*

0%* After Deductible

Hospital Services

Inpatient Hospital Facility

Outpatient Surgery

0%* After Deductible

25%* After Deductible

Mental Health/Chemical Dependency

Inpatient

Outpatient

0%* After Deductible

$30 Copay*

25%* After Deductible

Prescription Drug Coverage

Expanded Preventive Generic

Expanded Preventive Preferred Brand

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$10 Copay

$25 Copay

$10 Copay

$25 Copay*

50% Coinsurance*

$150 Copay after Deductible

Mail Order 90 Day Supply

$20 Copay

$50 Copay

$20 Copay after Deductible

$50 Copay after Deductible

50% Coinsurance*

Not Available

* Coinsurance

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

A Non-Embedded Deductible means that the family Deductible must be met before the Plan begins paying benefits that are subject to a Deductible

A Non-Embedded Out-of-Pocket maximum means that the family out-of-pocket maximum must be met before the Plan begins paying in full for all individuals.

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