High-deductible Health Plan (HDHP)
In-Network Benefits
Annual Deductible
$3,300 individual / $6,600 family
Annual Out-of-Pocket Maximum
$6,550 individual / $13,100 family
in-Network Copays
Teladoc
$55 until deductible is met, then 20%
Primary Care Office Visit Specialist Office Visit
20% after deductible
20% after deductible
Urgent Care (Clinic)
20% after deductible
Office Visit Diagnostic X-Ray & Labs
20% after deductible
In-network Physician Services
Office Services (X-rays, labs, surgeries)
20% after deductible
Allergy Injections
20% after deductible
Routine/Preventive Care Routine Gynecological Care
$0
$0
Mammograms
$0 for preventive
Cardiac Stress Test
$0 after deductible
In-network Hospital Services
Emergency Room Care Inpatient Hospital Services
20% after deductible
20% after deductible
Outpatient Diagnostic High-Tech Radiology
20% after deductible
Out-of-network Benefits
Annual Deductible
$6,400 individual / $12,800 family
Annual Out-of-Pocket Maximum Cost to Use Providers/Facilities
$13,100 individual / $26,200 family
40% after deductible
Prescription Benefits
Retail Prescription (30-Day Supply) Specific Preventive Generics
$0 copay
Generic
20% after deductible
Preferred brand, including specialty Nonpreferred brand, including specialty
20% after deductible
20% after deductible
Specialty
20% after deductible
Retail or Mail Order Prescription (90-Day Supply) Specific Preventive Generics
$0 copay
Generic
20% after deductible
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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