Medical and Pharmacy Coverage
J&L Ventures, LLC offers the following plans through Healthgram which mirror the plan offered through Healthgram. Please reference the Summary Plan Description for more details.
Insurance Carrier: Medical Plan Number:
Healthgram Medical Insurance
Base Plan
Premium Plan
In-Network: Office Visit Copay - Primary Care Office Visit Copay - Specialist Care
$45 - first 5 visits
$25 Copay per visit $50 Copay per visit $60 Copay per visit
Deductible; then 30% Coinsurance Deductible; then 30% Coinsurance $250 Copay; then 30% Coinsurance
Urgent Care Copay Emergency Room Care Preventative Visit Copay
$150 Copay; then 20% Coinsurance
$0 $0
$0 $0
Diagnostic Testing & Blood Work
Imaging
Deductible; then 30% Coinsurance
Deductible; then 20% Coinsurance
Coinsurance
70%
80%
Employee Deductible Family Deductible
$2,500 $7,500 $7,150 $14,300
$1,500 $4,500 $7,150 $14,300
Employee Out-of-Pocket Max Family Out-of-Pocket Max
Inpatient Hospital
Deductible; then 30% Coinsurance Deductible; then 30% Coinsurance
Deductible; then 20% Coinsurance Deductible; then 20% Coinsurance
Outpatient Hospital or Facility
Out-of-Network: Coinsurance
50%
50%
Employee Deductible Family Deductible
$7,500 $22,500 $21,450 $42,900
$4,500 $13,500 $21,450 $42,900
Employee Out-of-Pocket Max Family Out-of-Pocket Max
Prescription Drugs: ( 30 Day Supply) Rx Deductible
$1,000 Individual / $2,000 Family
$300 Individual / $600 Family
Tier 1 - Generic Tier 2 - Preferred
$15 / $30
$5 / $20
Deductible met; then $50 Copay Deductible met; then 20% Coinsurance Deductible met; then 20% Coinsurance
Deductible met; then $45 Copay Deductible met; then $80 Copay
Tier 3 - Non-Preferred
Tier 4 - Specialty
Pay at appropriate tier
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J & L VENTURES, LLC 2022 BENEFIT GUIDE
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