Medical Overview

Medical coverage offers health care protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.

Each plan offers comprehensive health care benefits, including free preventive care services and coverage for prescription drugs; however, the plans differ regarding your share of the costs toward:

  • Annual deductible amounts and out-of-pocket maximums.
  • Copay and coinsurance amounts that you pay toward the cost of covered services.

How a Health Plan Works

Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care. The plans have different:

  • Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
  • Out-of-pocket maximums– the most you will pay each year for eligible network services including prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
  • Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
  • Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.

Plan Comparison

Plan 1

Plan 2

Plan 3

In-Network

Out-of-Network

In-Network

Out-of-Network

In-Network

Out-of-Network

Calendar Year Deductible

Individual

$XXX

$XXX

$XXX

$XXX

$XXX

$XXX

Family

$XXX

$XXX

$XXX

$XXX

$XXX

$XXX

Calendar Year Out-of-Pocket Maximum (Includes Deductible)

Individual

$XXX

$XXX

$XXX

$XXX

$XXX

$XXX

Family

$XXX

$XXX

$XXX

$XXX

$XXX

$XXX

You pay

You pay

You pay

Coinsurance

Preventive Care

$XXX

$XXX

$XXX

$XXX

$XXX

$XXX

Primary Care Physician

$XXX

$XXX

$XXX

$XXX

$XXX

$XXX

Specialist

$XXX

$XXX

$XXX

$XXX

$XXX

$XXX

Urgent Care

$XXX

$XXX

$XXX

$XXX

$XXX

$XXX

Emergency Room

$XXX

$XXX

$XXX

$XXX

$XXX

$XXX

Pharmacy

Retail RX (up to 30-day supply)

Tier 1

$XXX

$XXX

$XXX

$XXX

$XXX

$XXX

Tier 2

$XXX

$XXX

$XXX

$XXX

$XXX

$XXX

Tier 3

$XXX

$XXX

$XXX

$XXX

$XXX

$XXX

Mail Order RX (up to 90-day supply)

Tier 1

$XXX

$XXX

$XXX

$XXX

$XXX

$XXX

Tier 2

$XXX

$XXX

$XXX

$XXX

$XXX

$XXX

Tier 3

$XXX

$XXX

$XXX

$XXX

$XXX

$XXX

* After deductible

*Out-of-network coverage is based on the negotiated rate. If your provider’s rate is higher, you will be responsible for paying the difference.