MEDICAL INSURANCE
The chart below provides a brief overview of the medical plan options available to you. This chart is intended only to highlight the benefits available and should not be relied upon to fully determine your coverage. If the below illustration of benefits conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your exact description of services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
The Company offers 2 medical plan options through Continental Group. To find participating providers for physician’s only go to www.multiplan.com and click on “Search for a Doctor”, check the box next to the “PHCS Practitioners Only” and enter your specific search criteria to find a doctor. If you have questions or concerns, please feel free to contact member services at 1-855- 824-9457
Base Copay Plan (Silver)
Buy-Up HSA Plan (Gold)
IN-NETWORK: Plan Year / Contract Year Basis Deductible (Individual / Family)
Calendar Year $3,000 / $6,000 $6,000 / $12,000
Calendar Year $2,000 / $4,000 $4,000 / $8,000
Maximum Out-of-Pocket (Individual/Family)
Out-of Pocket Max Includes
Deductible, Coinsurance, & Copays
Deductible & Coinsurance
Lifetime Major Medical Maximum
Unlimited
Unlimited
Coinsurance
100%
100%
Routine Preventive Services Wellness Immunizations / Flu Shots Mammography/Colonoscopy CO-PAYS PCP Required / Open Access Office Visits for Illness/Injury
Covered 100%
Covered 100%
Open Access $30 Copay $50 Copay $40 Copay $30 Copay
Open Access
No Charge After Deductible No Charge After Deductible No Charge After Deductible No Charge After Deductible No Charge After Deductible No Charge After Deductible No Charge After Deductible No Charge After Deductible No Charge After Deductible No Charge After Deductible No Charge After Deductible 10% After the Deductible 10% After the Deductible 10% After the Deductible
Specialist Visits
Physical/Occupational/Speech Therapy Chiropractic Care (20 visits per calendar year for)
Inpatient Hospital Outpatient Surgery
Deductible & Coinsurance Deductible & Coinsurance
Emergency Room (subject to a 30% penalty non accident/non-life threatening)
$300 Copay $75 Copay
Urgent Care
OUTPATIENT DIAGNOSTIC SERVICES Lab Services (Freestanding Lab) X-Ray Services (Freestanding X-Ray)
Covered 100%
$50 Copay $300 Copay
Complex Diagnostic PRESCRIPTIONS Retail (30 day supply)
$10/ $50/ $75
Specialty
50% up to $250 max Copay
Mail Order (90 day supply) OUT-OF-NETWORK: Deductible (Individual / Family)
2.5 X’s retail
$6,000/$12,000 $12,000/$24,000
$3,000/$6,000 $6,000/$12,000
Maximum Out-of-Pocket (Individual/Family)
Coinsurance
70%/30%
70%/30%
Tobacco User Rate Silver Copay Plan
Tobacco User Rate Gold HSA Plan
Standard Rate Silver Copay Plan
Buy-Up Option
Employee Cost Per Pay Period
Gold HSA Plan
Employee Only Employee + Spouse Employee + Child(ren)
$ 51.29 $156.59 $120.97 $190.09
$ 61.29 $166.59 $130.97 $200.09
$ 66.69 $203.59 $156.95 $233.41
$ 76.69 $213.59 $166.95 $243.41
Family
3
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