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Plan Summary
Plan Type EPO
Office Visit for Primary Doctor
Find Doctors 		$25 Copay
Office Visit for Specialist $60 Copay
Office Visit for Other Practitioner (Nurse, Physician Assistant) $25 Copay
Annual Deductible Individual: $900
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Coinsurance 30%
Retail Prescription Drugs Generic Drugs: $3 Copay;
Preferred Brand Drugs: $40 Copay;
Non-Preferred Brand Drugs: 45% Coinsurance after deductible;
Specialty Drugs: 50% Coinsurance after deductible;
Annual Out-of-Pocket Limit Individual: $8,400
Includes deductible
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage No 
Out-of-Country Coverage No.
Office Visit
Primary Care Physician Required Yes
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam No Charge
Periodic OB-GYN Exam No Charge
Well Baby Care No Charge
Emergency and Urgent Care
Emergency Room 30% Coinsurance after deductible
Emergency Ambulance Services 30% Coinsurance after deductible
Urgent Care Facility $60 Copay
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: $3 Copay;
Preferred Brand Drugs: $40 Copay;
Non-Preferred Brand Drugs: 45% Coinsurance after deductible;
Specialty Drugs: 50% Coinsurance after deductible;
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Mail Order Prescription Drugs N/A
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery Outpatient Surgery Physician/Surgical Services:
30% Coinsurance after deductible
Outpatient Facility Fee:
30% Coinsurance after deductible
Outpatient Lab/X-Ray Outpatient Lab:
30% Coinsurance after deductible
X-rays:
30% Coinsurance after deductible
Imaging (CT and PET scans, MRIs) 30% Coinsurance after deductible
Outpatient Mental Health $25 Copay
Outpatient Substance Abuse $25 Copay
Outpatient Rehabilitation Services (PT, OT, ST) $35 Copay, limited to 30 Visit(s) per Year
Inpatient Coverage
Hospitalization Inpatient Hospital Services:
30% Coinsurance after deductible
Inpatient Physician and Surgical Services:
30% Coinsurance after deductible
Skilled Nursing Facility 30% Coinsurance after deductible, limited to 120 Days per Admission
Inpatient Mental Health 30% Coinsurance after deductible
Inpatient Substance Abuse 30% Coinsurance after deductible
Home Healthcare 30% Coinsurance after deductible, limited to 100 Visit(s) per Year
Maternity Coverage
Pre & Postnatal Office Visit $25 Copay
Labor & Delivery Hospital Stay 30% Coinsurance after deductible
Pediatric Services
Dental Checkup for Children Not Covered
Vision Screening for Children No Charge, limited to 1 Exam(s) per Year
Eye Glasses for Children No Charge, limited to 1 Item(s) per Year
Major Dental Coverage (Pediatric) Not Covered
Additional Coverage
Chiropractic Coverage $60 Copay, limited to 30 Visit(s) per Year
Durable Medical Equipment 30% Coinsurance after deductible
Hospice 30% Coinsurance after deductible
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) Not Covered
Out-of-Network Coverage
Out-of-Network Authorization Required N/A
Out-of-Network Annual Deductible N/A
Out-of-Network Annual Coinsurance N/A
Out-of-Network Annual Out-of-Pocket Limit N/A
Additional Information
A.M. Best Rating N/A as of 11/10/2024
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Exclusions and Limitations

Important notices and disclaimers

  • The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.