HIGH-DEDUCTIBLE HEALTH PLAN (HDHP)
TRADITIONAL HEALTH PLAN (THP)
Benefits at a glance
Benefits at a glance
OUT-OF-NETWORK BENEFITS Annual Individual Deductible
IN-NETWORK BENEFIT Lifetime Maximum
IN-NETWORK BENEFIT Lifetime Maximum
OUT-OF-NETWORK BENEFITS Annual Individual Deductible
$4,000
UNLIMITED
UNLIMITED
$6,000
$11,000
Annual Individual Out-of-Pocket Maximum
$2,000
$3,000
$13,100
Annual Individual Deductible
Annual Individual Deductible
Annual Individual Out-of-Pocket Maximum
$8,000
Annual Family Deductible
$5,500
$6,550
$12,000
Annual Individual Out-of-Pocket Maximum
Annual Individual Out-of-Pocket Maximum
Annual Family Deductible
$22,000
Annual Family Out-of-Pocket Maximum
$4,000
$6,000
$26,200
Annual Family Deductible
Annual Family Deductible
Annual Family Out-of-Pocket Maximum
40% after deductible
$11,000
$13,100
Annual Family Out-of-Pocket Maximum
Annual Family Out-of-Pocket Maximum
40% after deductible
Providers/Facilities
Providers/Facilities
IN-NETWORK COPAYS Teladoc
IN-NETWORK COPAYS Teladoc
PRESCRIPTION BENEFITS**
PRESCRIPTION BENEFITS**
$0
$55
$45
Primary Care Office Visit
Primary Care Office Visit
Retail Prescription (30-Day Supply) Generic
Retail Prescription (30-Day Supply) Generic
$60
Specialist Office Visit
Specialist Office Visit Urgent Care (Clinic) Office Visit Diagnostic X-Ray & Labs IN-NETWORK PHYSICIAN SERVICES Office Services (X-rays, labs, surgeries)*
20% after deductible
$20 copay
$70
Urgent Care (Clinic)
20% after deductible Preferred Brand Nonpreferred Brand Specialty Retail or Mail Order Prescription (90-Day Supply) Generic
$40 copay
Preferred Brand
Office Visit Diagnostic X-Ray & Labs
$0 after copay
$80 copay
Nonpreferred Brand
IN-NETWORK PHYSICIAN SERVICES Office Services (X-rays, labs, surgeries)*
$40 or $80 copay , based on tier
Specialty
included in copay
20% after deductible
$0
Allergy Injections
Allergy Injections Routine/Preventive Care Routine Gynecological Care Mammograms
Retail or Mail Order Prescription (90-Day Supply) Generic $40 copay Preferred Brand $80 copay Nonpreferred Brand $160 copay
$0
Routine/Preventive Care
20% after deductible
Preferred Brand Nonpreferred Brand
$0
Routine Gynecological Care and/or Mammograms
$0
$0 for preventive
20% after deductible (available in 30-day supply only)
$0
Cardiac Stress Test
$0 after deductible
(available in 30-day supply only)
Cardiac Stress Test
Specialty
Specialty
IN-NETWORK HOSPITAL SERVICES Emergency Room Care
IN-NETWORK HOSPITAL SERVICES Emergency Room Care Inpatient Hospital Services Outpatient Diagnostic High-Tech Radiology All Other Outpatient Services
$500
Note: 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. *Sometimes not all services performed in a doctor’s office are BILLED by the doctor’s office, so you should always ask at the time of service what charges may be billed separately. **Refer to InsideAveritt.com to see a full list of preventive generic medicines covered at 100%.
Inpatient Hospital Services
Note: 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. *Sometimes not all services performed in a doctor’s office are BILLED by the doctor’s office, so you should always ask at the time of service what charges may be billed separately. **Refer to InsideAveritt.com to see a full list of preventive generic medicines covered at 100%.
20% after deductible
Outpatient Diagnostic High-Tech Radiology
20% after deductible
To see how much your prescriptions may cost through either plan, review our list of medications at InsideAveritt.com/benefits and click on the Express Scripts link.
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