Compare Plans

Compare Plans

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.


Summary Of Medical Benefits

Plan 1

In-Network

Out-of-Network

Deductible

Individual

Individual Under Family

Family

 

$1,600

$1,600

$4,800

 

$1,600

$1,600

$4,800

Out-Of-Pocket Maximum

Individual

Individual Under Family

Family

 

$1,600

$1,600

$4,800

 

$4,800

$4,800

$4,800

Preventive Care Services

No Charge

No Charge up to $500 per Deductible Year, then 45% Coinsurance After Deductible

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$35 Copay

$35 Copay

$35 Copay

 

45% Coinsurance After Deductible

45% Coinsurance After Deductible

45% Coinsurance After Deductible

Urgent Care Services

$35 Copay

45% Coinsurance After Deductible

Complex Imaging: MRI/CT/PET Scans

KIS Imaging

Non-KIS Imaging

 

No Charge

20% Coinsurance After Deductible

 

Not Covered

45% Coinsurance After Deductible

Inpatient Hospital Care

Facility Fee

Physician Fee

 

$500 Copay per confinement, then 20% Coinsurance After Deductible

20% Coinsurance After Deductible

 

45% Coinsurance After Deductible

45% Coinsurance After Deductible

Outpatient Procedures

Facility Fee

Physician Fee

 

$500 Copay, then 20% Coinsurance After Deductible

20% Coinsurance After Deductible

 

45% Coinsurance After Deductible

45% Coinsurance After Deductible

Emergency Room

Emergency Medical Transportation

20% Coinsurance After Deductible

20% Coinsurance After Deductible

20% Coinsurance After Deductible

20% Coinsurance After Deductible

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

$500 Copay per confinement, then 20% Coinsurance After Deductible

$35 Copay

 

45% Coinsurance After Deductible

45% Coinsurance After Deductible

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

$20 Copay

$25 Copay

$35 Copay

$20/$25/$35 Copay

 

$20 Copay

$25 Copay

$35 Copay

Not available

Over-the-Counter COVID-19 Tests

2 per year, per individual

 

No Charge

 

No Charge

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

 

 

Plan 2

In-Network

Out-of-Network

Deductible

Individual

Individual Under Family

Family

 

$800

$800

$2,400

 

$800

$800

$2,400

Out-Of-Pocket Maximum

Individual

Individual Under Family

Family

 

$800

$800

$2,400

 

$2,400

$2,400

$7,200

Preventive Care Services

No Charge

No Charge up to $500 per Deductible Year, then 45% Coinsurance After Deductible

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$30 Copay

$30 Copay

$30 Copay

 

45% Coinsurance After Deductible

45% Coinsurance After Deductible

45% Coinsurance After Deductible

Urgent Care Services

$30 Copay

45% Coinsurance After Deductible

Complex Imaging: MRI/CT/PET Scans

KIS Imaging

Non-KIS Imaging

 

No Charge

15% Coinsurance After Deductible

 

Not Covered

45% Coinsurance After Deductible

Inpatient Hospital Care

Facility Fee

Physician Fee

 

$500 Copay per confinement, then 15% Coinsurance After Deductible

15% Coinsurance After Deductible

 

45% Coinsurance After Deductible

45% Coinsurance After Deductible

Outpatient Procedures

Facility Fee

Physician Fee

 

$500 Copay, then 15% Coinsurance After Deductible

15% Coinsurance After Deductible

 

45% Coinsurance After Deductible

45% Coinsurance After Deductible

Emergency Room

Emergency Medical Transportation

15% Coinsurance After Deductible

15% Coinsurance After Deductible

15% Coinsurance After Deductible

15% Coinsurance After Deductible

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

$500 Copay per confinement, then 15% Coinsurance After Deductible

$30 Copay

 

45% Coinsurance After Deductible

45% Coinsurance After Deductible

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

$8 Copay

$15 Copay

$25 Copay

$8/$15/$25 Copay

 

$8 Copay

$15 Copay

$25 Copay

Not available

Over-the-Counter COVID-19 Tests

2 per year, per individual

 

No Charge

 

No Charge

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

 

 

Plan 3

In-Network

Out-of-Network

Deductible

Individual

Individual Under Family

Family

 

$300

$300

$900

 

$300

$300

$900

Out-Of-Pocket Maximum

Individual

Individual Under Family

Family

 

$600

$600

$1,800

 

$1,500

$1,500

$4,500

Preventive Care Services

No Charge

No Charge up to $500 per Deductible Year, then 45% Coinsurance After Deductible

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay

$25 Copay

$25 Copay

 

45% Coinsurance After Deductible

45% Coinsurance After Deductible

45% Coinsurance After Deductible

Urgent Care Services

$25 Copay

45% Coinsurance After Deductible

Complex Imaging: MRI/CT/PET Scans

KIS Imaging

Non-KIS Imaging

 

No Charge

10% Coinsurance After Deductible

 

Not Covered

45% Coinsurance After Deductible

Inpatient Hospital Care

Facility Fee

Physician Fee

 

$500 Copay per confinement, then 10% Coinsurance After Deductible

10% Coinsurance After Deductible

 

45% Coinsurance After Deductible

45% Coinsurance After Deductible

Outpatient Procedures

Facility Fee

Physician Fee

 

$500 Copay, then 10% Coinsurance After Deductible

10% Coinsurance After Deductible

 

45% Coinsurance After Deductible

45% Coinsurance After Deductible

Emergency Room

Emergency Medical Transportation

15% Coinsurance After Deductible

15% Coinsurance After Deductible

15% Coinsurance After Deductible

15% Coinsurance After Deductible

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

$500 Copay per confinement, then 10% Coinsurance After Deductible

$25 Copay

 

45% Coinsurance After Deductible

45% Coinsurance After Deductible

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

$5 Copay

$8 Copay

$18 Copay

$5/$8/$18Copay

 

$5 Copay

$8 Copay

$18 Copay

Not available

Over-the-Counter COVID-19 Tests

2 per year, per individual

 

No Charge

 

No Charge

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

 

 


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