MEDICAL BENEFITS
In-Network
Out-of-Network*
July 1 – June 30
Plan Year Deductible
Individual $1,000 Individual $2,250
Family $3,000 Family $4,500
Individual $1,000 Individual $2,500
Family $3,000 Family $5,000
Coinsurance Shown as a percentage
Maximum Out-of-Pocket Includes Deductible, Copays & Coinsurance
Individual $3,250
Family $7,500
Individual $3,500
Family $8,000
Primary Care Office Visit (General, Family, Pediatrician, Internist, OB/GYN)
$35 Copay
Deductible, 35%
Specialist Office Visit
$45 Copay
Deductible, 35%
Other Physician Services** Anesthesia Services, Radiology, Pathology, Obstetrical Delivery, Initial Newborn Pediatric Exam, Office Surgery, Dialysis Treatment Blue CareOnDemand (Telehealth) Powered by MD Live Preventive / Wellness Benefits In accordance with Health Care Reform Sustained Health Services (Services not covered at 100% under Preventive Care) $500 Annual Maximum Urgent Care (Not associated with a hospital) Freestanding Ambulatory Surgical Rotator Cuff Surgery, Total Knee Replacement, Total Hip Replacement, Spinal Fusion, Hernia Surgery
Deductible, 25%
Deductible, 35%
Urgent Care: $0 Copay Behavioral Health/Dermatology: $25 Copay
Not Covered
Covered in Full
Not Covered
$35 Copay
Not Covered
$35 Copay
Deductible, 35%
$500 Copay
Deductible, 35%
Freestanding Imaging Center MRI and CAT
$500 Copay
Deductible, 35%
Ambulance Air Ambulance
Deductible, 25% 75% of billed charges
Deductible, 25%
Emergency Room Facility Charges**
$150 Copay, Deductible, 25%
$150 Copay, Deductible, 25%
Emergency Room Professional Charges**
Deductible, 25%
Deductible, 25%
Inpatient Hospital Services
Deductible, 25%
Deductible, 35%
Outpatient Hospital Services**
Deductible, 25%
Deductible, 35%
Other Services Physical/Occupational Therapy (40 Visits) Home HealthCare (60 Days) Hospice Chiropractic ($2,000 Annual Maximum)
Deductible, 25%
Deductible 35%
* Providers may balance bill for non-covered charges. ** Non-Participating Provider at a Participating Facility (generally includes Ambulance Services, Emergency Services and Non-Emergency Services) are subject to In-Network Deductible, Coinsurance, and Out-of-Pocket Level.
See page 30 for employee premiums
CONMB Employee Benefit Guide 2025
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