HDHP Snapshot
Covered Services | In-Network Plan Participant Responsibility | Non-Network Plan Participant Responsibility | Special Comments |
Deductible, per plan year | $3,000 per participant with a $6,000 maximum per family | $7,500 per participant with a $15,000 maximum per family | |
Maximum Out-of-Pocket, per plan year | $3,000 per participant with a $6,000 maximum per family | $200,000 per participant with a $400,000 maximum per family | |
General Percentage Payment Rule | 100% after deductible | 50% after deductible | |
Office Visit - primary care | 100% after deductible | 50% after deductible | |
Office Visit - specialist | 100% after deductible | 50% after deductible | |
Urgent Care Center | 100% after deductible | 50% after deductible | |
Teladoc | 100% after deductible | N/A | Through December 31, 2022 General Health Teladoc visits are covered at $0 member cost-sharing. Not subject to deductible. |
Emergency Room | 100% after deductible | 100% after deductible | Co-payment is waived if admitted to the hospital on an emergency basis. Non-emergency treatment in the ER is not covered. |
Inpatient Hospital | 100% after deductible | 50% after deductible | Pre-certification is required |
Ambulance | 100% after deductible | 100% after deductible | Includes air ambulance. |
Single Diagnotic Test including lab and x-ray under $500 in allowable charges | 100% after deductible | 50% after deductible | |
Single Diagnostic Test including lab and x-ray over $500 allowable charges | 100% after deductible | 50% 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 | |||