2025 Benefits Enrollment Guide_Flexforce

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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