MEDICAL PLAN
SUMMARY OF COVERAGE
CU8J / RX K35S
CU8M / RX K35S
In Network Benefits
Choice Plus Gold
Choice Plus Platinum
Calendar
Calendar
Deductible
$500
$2,500 $5,000 Embedded
Individual
$1,000 Embedded
Family
Coinsurance Plan Pays
80%
80% 20%
20%
You Pay
Ded, Coins, All Copays
Ded, Coins, All Copays
Out of Pocket Maximum
$2,000 $4,000
$6,000 $12,000
Individual
Family
Commonly Used Services Primary Care Physician
$35 Copay**
$35 Copay** No $75 Copay No 100%
No
PCP Required
$75 Copay
Specialist
No
Referral Required
100%
Preventive Care Services
$49 Copay $50 Copay $500 Copay + Coins Ded + Coins
$49 Copay $50 Copay
Virtual Visits
Urgent Care
$500 Copay + Coins
Emergency Room
Ded + Coins
Major Diagnostics at Independent Facility
Ded + Coins @ Quest/Labcorp
Ded + Coins @ Quest/Labcorp
Labs at Independent Facility
Ded + Coins Ded + Coins Ded + Coins
X-rays at Independent Facility
Ded + Coins Ded + Coins Ded + Coins No Deductible
Hospitalization
Outpatient Surgery
No Deductible
Prescription Drugs
$10/$40/$125/$300 $10/$40/$125/$500
$10/$40/$125/$300 $10/$40/$125/$500 $25/$100/$312.50/$750
Rx
Specialty
$25/$100/$312.50/$750
Mail Order (90-day supply)
Out of Network Benefits Deductible Individual
$10,000 $20,000
$10,000 $20,000
Family
Coinsurance Plan Pays
50% 50%
50% 50%
You Pay
Out of Pocket Maximum Individual
$20,000 $40,000
$20,000 $40,000
Family
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Hometown Veterinary Partners Benefits Guide
MEDICAL PLAN
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