MEDICAL PLAN
SUMMARY OF COVERAGE
PLAN NAME
HDHP
BASE
MID
BUY UP
In Network Coverage Deductible (Individual / Family) Out-of-Pocket Max Primary Care Visit Specialist Visit Coinsurance
$2,500 / $5,000
$1,000 / $2,000
$1,000 / $2,000
$500 / $1,000
Plan pays 80% Plan pays 90% Plan pays 100% Plan pays 100%
$5,000 / $7,500
$2,000 / $4,000
$5,000 / $10,000
$1,000 / $2,000
20% after Deductible 20% after Deductible
$20 Copay $50 Copay
$25 Copay $50 Copay
$20 Copay $40 Copay
Telemedicine (MDLIVE)
20% after Deductible $20 or $50 Copay $25 or $50 Copay $20 or $40 Copay Outpatient Procedure 20% after Deductible 10% after Deductible 0% after Deductible 0% after Deductible Inpatient Visit 20% after Deductible 10% after Deductible 0% after Deductible 0% after Deductible Emergency Room 20% after Deductible $100 then 10% $100 Copay $100 Copay Urgent Care 20% after Deductible $55 then 10% $50 Copay $45 Copay Pharmacy (Retail - 30 day) 20% after Deductible $10 / $35 / $50 $15 / $35 / $50 $10 / $25 / $50 Out of Network Coverage Deductibles N/A $5,000 / $10,000 $1,000 / $2,000 $1,000 / $2,000 Coinsurance N/A Plan pays 50% Plan pays 60% Plan pays 60% Out-of-Pocket Max N/A $10,000 / $20,000 $8,000 / $16,000 $8,000 / $16,000
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MEDICAL PLAN I
SENDOSO BENEFITS GUIDE
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