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Not all coverage is the right coverage.

Your healthcare coverage is important to us. Age, family status, medical conditions, hobbies, lifestyle and a myriad of other factors will help you determine if you need a lot or a very little amount of health coverage. This summary will help you understand your plan and its coverage.

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Summary of Medical Benefits

Copay Plan - APPO/Aetna Network

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual + Spouse

Individual + Child(ren)

Family

 

$1,500

$2,500

$2,000

$3,000

 

NA

NA

NA

NA

Out-of-Pocket Maximum

Individual

Individual + Spouse

Individual + Child(ren)

Family

 

$4,000

$6,000

$5,000

$8,000

 

NA

NA

NA

N/A

Preventive Care Services

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$40 Copay

$75 Copay

20%*

 

Not Covered

Not Covered

Not Covered

Urgent Care Services

$100

Not Covered

Complex Imaging: MRI/CT/PET Scans

20%*

Not Covered

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

Not Covered

Not Covered

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

Not Covered

Not Covered

Emergency Room**

Emergency Medical Transportation**

$400

20%*

Not Covered

Not Covered

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$40

 

Not Covered

Not Covered

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$10 Copay

$45 Copay

$90 Copay

$250 Copay

Mail Order 90 Day Supply

$20 Copay

$90 Copay

$180 Copay

Not Covered

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

$20

$20

$20

$20

$20

 

$20

$20

$20

$20

$20

NOTE: * Coinsurance After Deductible

** Covered as in-network in true-emergency

Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions

 

 

 

 

 

 

HDHP - APPO/Aetna Network

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family Coverage

Individual + Spouse

Individual + Child(ren)

Family

 

$2,900

$3,300

$4,800

$4,000

$6,500

 

NA

NA

NA

NA

NA

Out-of-Pocket Maximum

Individual

Individual Under Family

Individual + Spouse

Individual + Child(ren)

Family

 

$5,000

$5,000

$8,250

$7,500

$10,000

 

NA

NA

NA

NA

N/A

Preventive Care Services

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

20%*

20%*

20%*

 

Not Covered

Not Covered

Not Covered

Urgent Care Services

20%*

Not Covered

Complex Imaging: MRI/CT/PET Scans

20%*

Not Covered

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

Not Covered

Not Covered

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

Not Covered

Not Covered

Emergency Room**

Emergency Medical Transportation**

20%*

20%*

Not Covered

Not Covered

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

20%*

 

Not Covered

Not Covered

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$10 Copay After Deductible

$45 Copay After Deductible

$90 Copay After Deductible

10%*

Mail Order 90 Day Supply

$20 Copay After Deductible

$90 Copay After Deductible

$180 Copay After Deductible

Not Available

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

$20 fee applies to deductible

$20 fee applies to deductible

$20 fee applies to deductible

$20 fee applies to deductible

$20 fee applies to deductible

 

$20 fee applies to deductible

$20 fee applies to deductible

$20 fee applies to deductible

$20 fee applies to deductible

$20 fee applies to deductible

NOTE: * Coinsurance After Deductible

** Covered as in-network in true-emergency

Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions

 

 

 

 

 

 

HDHP - Elite Network

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Individual + Spouse

Individual + Child(ren)

Family

 

$2,900

$3,300

$4,800

$4,000

$6,500

 

NA

NA

NA

NA

NA

Out-of-Pocket Maximum

Individual

Individual Under Family

Individual + Spouse

Individual + Child(ren)

Family

 

$5,000

$5,000

$4,800

$7,500

$10,000

 

NA

NA

NA

NA

NA

Preventive Care Services

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

20%*

20%*

20%*

 

Not Covered

Not Covered

Not Covered

Urgent Care Services

20%*

Not Covered

Complex Imaging: MRI/CT/PET Scans

20%*

Not Covered

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

Not Covered

Not Covered

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

Not Covered

Not Covered

Emergency Room**

Emergency Medical Transportation**

20%*

20%*

Not Covered

Not Covered

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

20%*

 

Not Covered

Not Covered

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$10 Copay After Deductible

$45 Copay After Deductible

$90 Copay After Deductible

10%*

Mail Order 90 Day Supply

$20 Copay After Deductible

$90 Copay After Deductible

$180 Copay After Deductible

Not Available

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

$20 fee applies to deductible

$20 fee applies to deductible

$20 fee applies to deductible

$20 fee applies to deductible

$20 fee applies to deductible

 

$20 fee applies to deductible

$20 fee applies to deductible

$20 fee applies to deductible

$20 fee applies to deductible

$20 fee applies to deductible

NOTE: * Coinsurance After Deductible

** Covered as in-network in true-emergency

Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions

 

 

 

 

 

 

 

 

Dental Plan

In-Network & Out-of-Network

Deductible

Individual Coverage

Individual + Spouse / Individual + Child

Family Coverage

 

$50

$75

$100

Maximums

Annual Maximum per Individual

Orthodontic Maximum per Individual

 

$2,000

$2,000

Dental Only Premiums

Employee Only

Employee + Spouse

Employee + Child

Family

 

$40

$90

$75

$110

Preventive/Diagnostic Care

Dental Exams

Cleanings

Fluoride Treatments

Preventive X-Rays

Full Mouth X-Rays

 

No Charge

No Charge

No Charge

No Charge

No Charge

Basic Services

Fillings - Amalgam, Composite, Porcelain & Plastic

Simple Extractions

Oral Surgery

Periodontics

Endodontics

 

10%*

20%*

20%*

20%*

20%*

Major Services

Crowns & Gold Fillings

Inlays & Onlays

Pontics

Dental Implant

 

50%*

50%*

50%*

50%*

Prosthetics

Bridges

Dentures

Partial Dentures

 

50%*

50%*

50%*

Orthodontics

Orthodontics (For dependents under age 16)

 

50%*

NOTE: * Coinsurance after deductible

This serves as a summary of your benefit plan only. Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions.

 

 

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