HIGH-DEDUCTIBLE HEALTH PLAN (HDHP)
IN-NETWORK BENEFITS
ANNUAL DEDUCTIBLE
$3,200 individual / $6,400 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 URGENT CARE (CLINIC) OFFICE VISIT DIAGNOSTIC X-RAY & LABS
20% after deductible
IN-NETWORK PHYSICIAN SERVICES
OFFICE SERVICES (X-RAYS, LABS, SURGERIES)
20% after deductible
ALLERGY INJECTIONS ROUTINE/PREVENTIVE CARE ROUTINE GYNECOLOGICAL CARE MAMMOGRAMS
$0
$0 for preventive
CARDIAC STRESS TEST
$0 after deductible
IN-NETWORK HOSPITAL SERVICES
EMERGENCY ROOM CARE
INPATIENT HOSPITAL SERVICES 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) CERTAIN PREVENTIVE GENERICS SEE INSIDEAVERITT.COM FOR THE FULL LIST
$0 copay
GENERIC
PREFERRED BRAND, INCLUDING SPECIALTY NONPREFERRED BRAND, INCLUDING SPECIALTY SPECIALTY RETAIL OR MAIL ORDER PRESCRIPTION (90-DAY SUPPLY) CERTAIN PREVENTIVE GENERICS SEE INSIDEAVERITT.COM FOR THE FULL LIST
20% after deductible
$0 copay
GENERIC
20% after deductible PREFERRED BRAND NONPREFERRED BRAND 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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