Compare Plans

Summary of Medical Benefits

PPO 2 Plan

In-Network

Out-of-Network

Embedded Deductible

Individual

Family

$1,000

$2,000

$4,000

Embedded Out-of-Pocket Maximum

Individual

Family

$6,000

$12,000

$24,000

WellVia (a Recuro Health company)

Telemedicine Services

No Charge

Preventive Care

No Charge

Office Visits

Primary Services

Specialist Services

Chiropractic Services

$20 Copay

$50 Copay

25% Coinsurance

25%* after Ded

50%* after Ded

Urgent Care Services

$40 Copay

25%* after Ded

Emergency Services**

Emergency Room

Emergency Medical Transportation

$200 Copay

0%* after Ded

$200 Copay

0%* after Ded

Hospital Services

Inpatient Hospital Facility

Outpatient Surgery

0%* after Ded

$500 Copay after Deductible

25%* after Ded

Diagnostic Testing & Imaging

Labs

X-rays

CT/PET/MRI

$40 Copay

$60 Copay

$200 Copay

25%* after Ded

Mental Health/Chemical Dependency

Inpatient

Outpatient

0%* after Ded

$50 Copay

25%* after Ded

Prescription Drug Coverage

Generic

Preferred brand

Non-Preferred Generics & Brand

Specialty

Retail 30-Day Supply

$10 Copay

$25 Copay

50% Coinsurance

$200 Copay

Mail Order 90-Day Supply

$20 Copay

$50 Copay

50% Coinsurance

Not Available

*Coinsurance

**Covered as In-Network if deemed true emergency

PPO 5 Plan

In-Network

Out-of-Network

Embedded Deductible

Individual

Family

$3,000

$6,000

$5,000

$10,000

Embedded Out-of-Pocket Maximum

Individual

Family

$6,750

$13,500

$15,000

$30,000

WellVia (a Recuro Health company)

Telemedicine Services

No Charge

Preventive Care

No Charge

50% Coinsurance

Office Visits

Primary Services

Specialist Services

Chiropractic Services

$20 Copay

$75 Copay

25%* after Ded

50%* after Ded

Urgent Care Services

$50 Copay

50%* after Ded

Emergency Services**

Emergency Room

Emergency Medical Transportation

$300 Copay after Deductible

0%* after Ded

$300 Copay after Deductible

0%* after Ded

Hospital Services

Inpatient Hospital Facility

Outpatient Surgery

0%* after Ded

$750 Copay after Deductible

50%* after Ded

Diagnostic Testing & Imaging

Labs

X-rays

CT/PET/MRI

$50 Copay after Deductible

$75 Copay after Deductible

$300 Copay after Deductible

50%* after Ded

Mental Health/Chemical Dependency

Inpatient

Outpatient

0%* after Ded

$75 Copay

50%* after Ded

Prescription Drug Coverage

Generic

Preferred brand

Non-Preferred Generics & Brand

Specialty

Retail 30-Day Supply

$10 Copay

$25 Copay

50% Coinsurance

$200 Copay

Mail Order 90-Day Supply

$20 Copay

$50 Copay

50% Coinsurance

Not Available

*Coinsurance

**Covered as In-Network if deemed true emergency

HSA 1 Plan

In-Network

Out-of-Network

Embedded Deductible

Individual

Family

$3,000

$6,000

$5,000

$10,000

Embedded Out-of-Pocket Maximum

Individual

Family

$6,750

$13,500

$10,000

$20,000

WellVia (a Recuro Health company)

Telemedicine Services

No Charge

Preventive Care

No Charge

50%* after Ded

Office Visits

Primary Services

Specialist Services

Chiropractic Services

10%* after Ded

50%* after Ded

Urgent Care Services

10%* after Ded

50%* after Ded

Emergency Services**

Emergency Room

Emergency Medical Transportation

10%* after Ded

Hospital Services

Inpatient Hospital Facility

Outpatient Surgery

10%* after Ded

50%* after Ded

Diagnostic Testing & Imaging

Labs

X-rays

CT/PET/MRI

10%* after Ded

50%* after Ded

Mental Health/Chemical Dependency

Inpatient

Outpatient

10%* after Ded

50%* after Ded

Prescription Drug Coverage

Generic

Preferred brand

Non-Preferred Generics & Brand

Specialty

Expanded Preventive

Retail 30-Day Supply

$10 Copay after Deductible

$25 Copay after Deductible

50%* after Ded

$200 Copay after Deductible

Applicable copay above, no Deductible

Mail Order 90-Day Supply

$20 Copay after Deductible

$50 Copay after Deductible

50%* after Ded

Not Available

Applicable coinsurance above, no Deductible

*Coinsurance

**Covered as In-Network if deemed true emergency

HSA 2 Plan

In-Network

Out-of-Network

Embedded Deductible

Individual

Family

$5,000

$10,000

$20,000

Embedded Out-of-Pocket Maximum

Individual

Family

$6,750

$13,500

$15,000

$30,000

WellVia (a Recuro Health company)

Telemedicine Services

No Charge

Preventive Care

No Charge

50%* after Ded

Office Visits

Primary Services

Specialist Services

Chiropractic Services

20%* after Ded

50%* after Ded

Urgent Care Services

20%* after Ded

50%* after Ded

Emergency Services**

Emergency Room

Emergency Medical Transportation

20%* after Ded

Hospital Services

Inpatient Hospital Facility

Outpatient Surgery

20%* after Ded

50%* after Ded

Diagnostic Testing & Imaging

Labs

X-rays

CT/PET/MRI

20%* after Ded

50%* after Ded

Mental Health/Chemical Dependency

Inpatient

Outpatient

20%* after Ded

50%* after Ded

Prescription Drug Coverage

Generic

Preferred brand

Non-Preferred Generics & Brand

Specialty

Expanded Preventive

20%* after Ded

50%* after Ded

20%* after Ded

Applicable coinsurance above, no Deductible

20%* after Ded

50%* after Ded

20%* after Ded

Applicable coinsurance above, no Deductible

*Coinsurance

**Covered as In-Network if deemed true emergency

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