Medical and Pharmacy Coverage
Zoe Pediatrics offers the following medical plans.
Please reference the Summary Plan Description for more details.
Insurance Carrier:
Imagine360 Medical Insurance
Plan Type:
Base Plan
Buy-Up Plan
In-Network: Office Visit Copay - Primary Care Office Visit Copay - Specialist Care
100%
100%
$60 Copay
$60 Copay
Urgent Care Copay Emergency Room Care Preventative Visit Copay
100% after $75 Copay
100% after $75 Copay
$500 Copay; waived if admitted
$500 Copay; waived if admitted
100%; Deductible waived 80%; Deductible applies 80%; Deductible applies
100%; Deductible waived 90%; Deductible applies 90%; Deductible applies
Diagnostic Testing & Blood Work
Advanced Imaging
Coinsurance
80%
90%
Employee Deductible Family Deductible
$3,000 $9,000
$1,500 $4,500
Employee Out-of-Pocket Max Family Out-of-Pocket Max
$7,900 (includes deductible & copays) $15,800 (includes deductible & copays)
$4.500 (includes deductible & copays) $9,000 (includes deductible & copays)
Inpatient Hospital
80%; Deductible applies 80%; Deductible applies
90%; Deductible applies 90%; Deductible applies
Outpatient Hospital or Facility
Out-of-Network: Coinsurance Employee Deductible
50%
50%
$9,000 $27,000 $23,700 $47,400
$4,500 $13,500 $13,500 $27,000
Family Deductible
Employee Out-of-Pocket Max Family Out-of-Pocket Max
Prescription Drugs: ( 30 Day Supply) Tier 1 - Generic
$15 Copay $35 Copay $60 Copay
Tier 2 - Preferred
Tier 3 - Non-Preferred
Tier 4 - Specialty
25% up to $350 Maximum
Employee Bi-Weekly Deduction Employee Only
$0.00
$27.06 $324.12 $228.54 $525.60
Employee + Spouse Employee + Child(ren)
$265.95 $180.38 $446.33
Family
Zoe Pediatrics 2023 Enrollment Guide
6
Made with FlippingBook - professional solution for displaying marketing and sales documents online