BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
The Percentage of Covered Expenses the Plan Pays See Definitions section for an explanation of Maximum Reimbursable Charge. Note: Calendar Year Deductible Individual Family Maximum Family Maximum Calculation Collective Deductible: All family members contribute towards the family deductible. An individual cannot have claims covered under the plan coinsurance until the total family deductible has been satisfied. "No charge" means an insured person is not required to pay Coinsurance. Combined Medical/Pharmacy Calendar Year Deductible Combined Medical/Pharmacy Deductible: includes retail and home delivery drugs Home Delivery Pharmacy Costs Contribute to the Combined Medical/Pharmacy Deductible Combined Out-of-Pocket Maximum for Medical and Pharmacy expenses
80%
50%
$2,250 per person $4,500 per family
$4,500 per person $9,000 per family
Yes
Yes
Yes
In-Network coverage only
Individual – Employee Only Individual – within a Family Family Maximum Family Maximum Calculation Individual Calculation:
$5,250 per person $8,000 per person $10,500 per family
$10,500 per person $16,000 per person $21,000 per family
Family members meet only their individual Out-of-Pocket and then their claims will be covered at 100%; if the family Out-of-Pocket has been met prior to their individual Out-of- Pocket being met, their claims will be paid at 100%.
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