Medical & RX Insurance

Benefit

Basic Plan

Plus Plan

Calendar Year Deductible

IN-NETWORK **

$3,150 Employee only

$5,300 Family (EE + 1 or more)

$1,650 Employee only

$3,300 Family (EE + 1 or more)

Out of Pocket Maximum

  IN-NETWORK **

$6,300 Employee only

$10,600 Family

$3,300 Employee only

$6,600 Family

Annual Maximum

No Maximum

No Maximum

Routine/Preventive Care:

Annual physical (including routine lab work), OB/GYN, mammograms, prostate exams, immunizations, flu shots, colonoscopy (including lab work; limited to 1 every 5 years for covered persons between the ages of 45 and 50 years, and 1 every 24 months for covered persons ages 50 years and older)

Deductible waived; Plan pays 100%

Deductible waived; Plan pays 100%

Routine/Preventive Well Baby/Child Care 0-7 Years:

Includes office visits, routine exam, preventive immunizations

Deductible waived; Plan pays 100%

Deductible waived; Plan pays 100%

Prescription Drugs (retail pharmacy)

80% after deductible*

(*certain generic medications are not subject to the deductible – please refer to SPD for more detail)

80% after deductible*

(*certain generic medications are not subject to the deductible – please refer to SPD for more detail)

Prescription Drugs (mail order)

80% after deductible*

(*certain generic medications are not subject to the deductible – please refer to SPD for more detail)

80% after deductible*

(*certain generic medications are not subject to the deductible – please refer to SPD for more detail)

Office Visit

80% after deductible

80% after deductible

Specialist Office Visit

80% after deductible

80% after deductible

Emergency Room

80% after deductible

80% after deductible

Urgent Care

80% after deductible

80% after deductible

In-patient Hospital

80% after deductible

80% after deductible

Durable Medical Equipment

80% after deductible

80% after deductible