Your safety net for comprehensive, affordable health care. This is designed as a High Deductible Health Plan (HDHP) and qualifies for a Health Savings Account (HSA).
| Basic plan summary | |
|---|---|
| Plan type | PPO (Preferred Provider Organization) – Allows you to choose to receive care from network providers of your choice. |
| Deductible individual | $2,500 |
| Deductible family | $5,000 |
| Coinsurance | 20% after deductible |
| Individual out-of-pocket maximum after deductible | $2,500 |
| Family out-of-pocket maximum after deductible | $5,000 |
| Individual lifetime maximum | Unlimited |
| Dependent coverage | Eligible children covered to age 26 |
| HSA eligibility | Yes |
| Doctor office visits (illness and injury) | |
| Office visit - history and exam | Subject to deductible |
| Office visit - specialist | Subject to deductible |
| How can I find a doctor in this plan's Network? | Search for a doctor or hospital here |
| Do I need permission from my primary care doctor to see a specialist? | No |
| Do I need authorization before seeing an out-of-network doctor? | No |
| Hospital services | Your cost sharing |
| Emergency room | Subject to deductible |
| Outpatient Lab/X-ray | Subject to deductible |
| Outpatient surgery | Subject to deductible |
| Hospitalization | Subject to deductible |
| Preventive care | |
| As part of the Affordable Care Act, preventive services are paid at 100% of the allowable charge for new enrollees after Sept. 23, 2010. This includes routine screenings, immunizations, checkups and counseling received to prevent illness or disease. There are also several preventive services for women paid at 100% of the allowable charge for new enrollees on or after Aug. 1, 2012. For a complete listing, please click here. | |
| Prescription drug | |
| Generic | Subject to deductible |
| Brand | Subject to deductible |
| Non-formulary | Subject to deductible |
| Prescription drug – Mail order | |
| Generic | Not covered |
| Brand | Not covered |
| Non-formulary | Not covered |
| Maternity coverage | |
| Pre and postnatal office visit | Subject to deductible (spouses must be enrolled in same plan) |
| Labor and delivery hospital stay | Subject to deductible (spouses must be enrolled in same plan) |
| Additional coverage | |
| Mental health | Subject to deductible |
| Substance abuse | Subject to deductible |
| Optional benefits | |
| Dental program | Dental coverage options |
| Hospital Indemnity Plan (HIP) | Cash benefits during hospitalization |
| Life insurance | Protection up to $50,000 |
| LTC Blue | Long-term care insurance |
| Plan 150 | Cancer policy |
Exclusions
See the Exclusions page for details.
Additional Program Information
More Information
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