Covered Services

Plan Participant Responsibility

Special Comments

Deductible, per plan year

$250 per participant with a 
$750 per family maximum

Maximum Out-of-Pocket. per plan year

$5,500 per participant with a $11,000 per family maximum

General Percentage Payment Rule

20% after deductible

Office Visit - Primary Care

$30 co-payment, deductible waived

Office Visit - Specialist

$40 co-payment, deductible waived

Urgent Care Center

$35 co-payment, deductible waived

Teladoc

$0 copayment first two (2) consultations per plan year, then $40 per consultation, deductible waived

Emergency Room

$250 co-payment, deductible and 20% coinsurance 

Co-payment waived if admitted to hospital on an emergency basis. Non-emergency treatment in the ER is not covered.

Inpatient Hospital

20% after deductible

Pre-certification required

Ambulance

20% coinsurance, deductible waived

Includes air ambulance.
Precertification required for fixed wing ambulance and non-emergent air ambulance. 

Non-Hospital Physical Therapy/Occupational Therapy

$10 copayment

Hospital owned facilities are subject to Deductible and Coinsurance

Single Diagnostic Test including Lab or X-Ray under $500 in allowable charges

$30 copayment - primary physician office
$40 copayment - specialist office

Single Diagnostic Test including Lab or X-Ray over $500 in allowable changes

20% after deductible

Precertification required for any single diagnostic test over $1,000 in billed charges

Please see the Summary Plan Description for the full Schedule of Benefits, Exclusions and Precertification Requirements