|
| National Market Place Plan Level Equilavent |
| Medical Coverage |
| Wellness Exams & Preventive Visits |
| Deductible |
| Coinsurance |
| Primary Care Provider(PCP)
Virtual Visit(VV)
Specialists
|
| Inpatient Hospital |
| Outpatient Hospital |
| Emergency Room |
| Urgent Care/Convenience Care |
| Annual Out-Of-Pocket
Maximum |
| Lifetime Maximum |
| Prescription Drugs |
| Retail Network (31 days) |
| Mail Order (90 days) |
| Specialty Drugs |
|
| HDHP 3000 |
| Qualified High Deductible Plan |
| In-Network |
Out-of-Network |
| 100% #br#
Not Subject
To Deductible |
Mammogram &
Pap Smear Only #br#
70% |
| NON-EMBEDDED #br#
$3,000/Ind. #br#
$6,000/Fam. |
NON-EMBEDDED #br#
$4,000/Ind. #br#
$8,000/Fam |
| 100% |
70% |
| 100% |
70% |
| 100% |
70% |
| 100% |
70% |
| 100% |
| 100% |
70% |
| NON-EMBEDDED #br#
$3,000/Ind. #br#
$6,000/Fam. |
NON-EMBEDDED #br#
$7,500/Ind. #br#
$15,000/Fam. |
| UNLIMITED |
| In-Network |
Out-of-Network |
| 100% |
Not Covered |
|
| HDHP 4000 |
| Qualified High Deductible Plan |
| In-Network |
Out-of-Network |
| 100% #br#
Not Subject
To Deductible |
Mammogram &
Pap Smear Only #br#
60% |
| $4,000/Ind. #br#
$8,000/Fam. |
$10,000/Ind. #br#
$20,000/Fam. |
| 80% |
60% |
| 80% |
60% |
| 80% |
60% |
| 80% |
60% |
| 80% |
| 80% |
60% |
| $7,050/Ind. #br#
$14,100/Fam. |
$15,000/Ind. #br#
$30,000/Fam. |
| UNLIMITED |
| In-Network |
Out-of-Network |
| 80% |
Not Covered |
|
| Surest Gold |
| Copay Only |
| In-Network |
Out-of-Network |
| 100% with #br#
No Copay |
100% after #br#
$100 Copay |
| None |
None |
| None |
None |
| PCP & Specialist: #br#
100% after Copay #br#
(ranges $25-$130)
#br# #br#
Virtual Visit: #br#
Primary & Urgent
Care #br#
100% No Copay
#br# #br#
Specialist: #br#
$0-$130 |
PCP & Specialist: #br#
100% after #br#
$220 Copay
#br# #br#
Virtual Visit: #br#
Not Covered |
| 100% after Copay #br#
(up to $3,500) |
100% after Copay #br#
(up to $10,000) |
| 100% after Copay #br#
(up to $3,500) |
100% after Copay #br#
(up to $10,000) |
| 100% after $900 Copay #br#
(waived if admitted) |
| 100% after #br#
$80 Copay |
100% after #br#
$210 Copay |
| $5,500/Ind. #br#
$11,000/Fam. |
$11,000/Ind. #br#
$22,000/Fam. |
| UNLIMITED |
| Tier 1 |
Tier 2 |
Tier 3 |
| $15 |
$40 |
$60 |
| $35 |
$100 |
$150 |
| $200 |
|
