Traditional Health Plan (THP)
High-deductible Health Plan (HDHP)
In-Network Benefits
In-Network Benefits
Annual Deductible
Annual Deductible
$2,000 individual / $4,000 family
$3,300 individual / $6,600 family
Annual Out-of-Pocket Maximum
Annual Out-of-Pocket Maximum
$5,500 individual / $11,000 family
$6,550 individual / $13,100 family
in-Network Copays
in-Network Copays
Teladoc
Teladoc
$0
$55 until deductible is met, then 20%
Primary Care Office Visit Specialist Office Visit
Primary Care Office Visit Specialist Office Visit
$45
20% after deductible
$60
20% after deductible
Urgent Care (Clinic)
Urgent Care (Clinic)
$70
20% after deductible
Office Visit Diagnostic X-Ray & Labs
Office Visit Diagnostic X-Ray & Labs
$0 after copay
20% after deductible
Hearing Aids (One per year, per ear, every 3 years)
In-network Physician Services
$0 ($5,000 maximum for 18+)
In-network Physician Services
Office Services (X-rays, labs, surgeries)
20% after deductible
Office Services (X-rays, labs, surgeries)
Allergy Injections
included in copay
20% after deductible
Allergy Injections
Routine/Preventive Care Routine Gynecological Care
$0
$0
Routine/Preventive Care
$0
$0
Routine Gynecological Care and/or Mammograms
Mammograms
$0
$0 for preventive
Cardiac Stress Test
Cardiac Stress Test
$0
$0 after deductible
In-network Hospital Services
In-network Hospital Services
Emergency Room Care Inpatient Hospital Services
Emergency Room Care Inpatient Hospital Services
$500
20% after deductible
20% after deductible
20% after deductible
Outpatient Diagnostic High-Tech Radiology
Outpatient Diagnostic High-Tech Radiology
20% after deductible
20% after deductible
Out-of-network Benefits
Out-of-network Benefits
Annual Deductible
Annual Deductible
$4,000 individual / $8,000 family
$6,400 individual / $12,800 family
Annual Out-of-Pocket Maximum Cost to Use Providers/Facilities
Annual Out-of-Pocket Maximum Cost to Use Providers/Facilities
$11,000 individual / $22,000 family
$13,100 individual / $26,200 family
40% after deductible
40% after deductible
Prescription Benefits
Prescription Benefits
Retail Prescription (30-Day Supply) Specific Preventive Generics
Retail Prescription (30-Day Supply) Specific Preventive Generics
$0 copay
$0 copay
Generic
Generic
$20 copay
20% after deductible
Preferred brand, including specialty Nonpreferred brand, including specialty
Preferred brand, including specialty Nonpreferred brand, including specialty
$40 copay
20% after deductible
$80 copay
20% after deductible
Retail or Mail Order Prescription (90-Day Supply) Specific Preventive Generics
Specialty
20% after deductible
Retail or Mail Order Prescription (90-Day Supply) Specific Preventive Generics
$0 copay
Generic
$40 copay
$0 copay
Preferred brand
Generic
$80 copay
20% after deductible
Nonpreferred brand $160 copay This is a summary of your coverage only. In-network services are based on negotiated charges; out-of-network services are based on reasonable and customary (R&C) charges.
Preferred brand
20% after deductible
Nonpreferred brand 20% after deductible This is a summary of your coverage only. In-network services are based on negotiated charges; out-of-network services are based on reasonable and customary (R&C) charges.
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