Covered Services

Plan Participant Responsibility 

Special Comments

$500 per participant with a $1,500 maximum per family

Maximum Out-of-Pocket, per plan year

$9,100 per participant with a $18,200 maximum per family

20% after deductible

Office Visit - primary care

$30 co-payment, deductible waived

Office Visit - specialist

$40 co-payment, deductible waived

$35 co-payment, deductible waived

$0 co-payment first two consultations per plan year then $40 co-payment per consultation, deductible waived

Emergency Room 

$250 co-payment, deductible and 20% coinsurance

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

Inpatient Hospital

20% after deductible

Pre-certification is required

Ambulance

20% coinsurance, deductible waived

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

Non-Hospital Physical or Occupational Therapy

$10 copayment

Hospital owned PT and OT are subject dedutible and coinsurance. 

Single Diagnotic Test including lab and x-ray under $500 in allowable charges

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

Single Diagnostic Test including lab and x-ray over $500 allowable charges

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