2025 Benefits Enrollment Guide_Flexforce

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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