Covered Services

In-Network Plan Participant Responsibility 

Non-Network Plan Participant Responsibility

Special Comments

Deductible, per plan year

$3,200 per participant with a $6,400 maximum per family

$7,500 per participant with a $15,000 maximum per family

Maximum Out-of-Pocket, per plan year

$3,200 per participant with a $6,400 maximum per family

$200,000 per participant with a $400,000 maximum per family

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

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

Single Diagnostic 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