Traditional Health Plan (THP)
In-Network Benefits
Annual Deductible
$2,000 individual / $4,000 family
Annual Out-of-Pocket Maximum
$5,500 individual / $11,000 family
in-Network Copays
Teladoc
$0
Primary Care Office Visit Specialist Office Visit
$45
$60
Urgent Care (Clinic)
$70
Office Visit Diagnostic X-Ray & Labs
$0 after copay
Hearing Aids (One per year, per ear, every 3 years)
$0 ($5,000 maximum for 18+)
In-network Physician Services
Office Services (X-rays, labs, surgeries)
included in copay
Allergy Injections
$0
Routine/Preventive Care
$0
Routine Gynecological Care and/or Mammograms
$0
Cardiac Stress Test
$0
In-network Hospital Services
Emergency Room Care Inpatient Hospital Services
$500
20% after deductible
Outpatient Diagnostic High-Tech Radiology
20% after deductible
Out-of-network Benefits
Annual Deductible
$4,000 individual / $8,000 family
Annual Out-of-Pocket Maximum Cost to Use Providers/Facilities
$11,000 individual / $22,000 family
40% after deductible
Prescription Benefits
Retail Prescription (30-Day Supply) Specific Preventive Generics
$0 copay
Generic
$20 copay
Preferred brand, including specialty Nonpreferred brand, including specialty
$40 copay
$80 copay
Retail or Mail Order Prescription (90-Day Supply) Specific Preventive Generics
$0 copay
Generic
$40 copay
Preferred brand
$80 copay
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.
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