|
| 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 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 |
|
