Zoe Center for Pediatric and Adolescent Health, LLC
Benefits & Total Rate Overview: Level Funding Q3P2 Triple Option Plan Q3 OAP BASE (37496493)
Q3 OAP BUYUP (37497303) Open Access Plus $1,500 / $4,500 (Non-Collective) $4,500 / $9,000 (Non-Collective)
Q3 HSA (37516588)
Open Access Plus
HSA Open Access Plus
Product
In-Network Deductible (Single/Family)
$3,000 / $9,000 (Non-Collective) $7,900 / $15,800 (Non-Collective)
$6,000 / $12,000 (Non-Collective) $6,000 / $12,000 (Non-Collective)
Out-of-Pocket (Single/Family)
80% 100%
90% 100%
100%
Coinsurance
100% ^
Physician Services - PCP Physician Services - SPC Inpatient Services Outpatient Services
$60 + 100%
$60 + 100%
$60 + 100% ^
80% ^ 80% ^ 80% ^ 80% ^ 100%
90% ^ 90% ^ 90% ^ 90% ^ 100%
90% ^ 90% ^ 90% ^ 90% ^ 100% ^
Emergency Room
Urgent Care
MDLive Virtual - UC Lab Services - OV Lab Services - Ind. Lab
Same as Phy. OV
Same as Phy. OV
Same as Phy. OV
80% ^ 80% ^
90% ^ 90% ^
90% ^ 100% ^
Adv. Radiology - Outpatient
Same as Spc. OV Same as Spc. OV Same as Spc. OV
Same as Spc. OV Same as Spc. OV Same as Spc. OV
Same as Spc. OV Same as Spc. OV Same as Spc. OV
Outpatient PT
Outpatient Speech & OT
Chiropratic Care Pharmacy Pharmacy Network
Cigna 90 Now Walgreens
Cigna 90 Now Walgreens
Cigna 90 Now Walgreens
NA
NA
NA
Client Anchor Formulary/PDL
Performance $15/$35/$60 $38/$88/$150
Performance $15/$35/$60 $38/$88/$150
Performance
$15 ^/$35 ^/$60 ^ $38 ^/$88 ^/$150 ^
Retail
Home Delivery Drug Out-of-Network Deductible
$3,000/$9,000 $7,900/$15,800
$1,500/$4,500 $4,500/$9,000
$12,000/$24,000 $12,000/$24,000
Out-of-Pocket Coinsurance Total Rates Employee Emp + Spouse Emp + Child(ren)
60%
70%
80%
88
$524.44 30
$583.47 $1,254.48 $1,038.58 $1,709.58
0 0 0 0
$411.30 $884.28 $732.09 $1,205.09
1
$1,127.52 $933.48 $1,536.58
2 3 3
9 0
Emp + Family
Grand Total Monthly Cost
$83,943.46
Services where plan deductible applies are noted with a caret (^).
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