Medical & Prescription Plans

In our continuous effort to ensure the well-being of you and your family, [COMPANY NAME] will continue to provide [number of medical plans, who they're administered by, and the network]

The table below summarizes the key features of the medical coverage. The deductibles, copays and coinsurance percentages in the following chart indicate the amounts for which you are responsible.

BENEFIT
[Provider Name] IN-NETWORK PLAN
[Provider Name] PLUS PLAN (CLOSED)
[Provider Name] HDHP WITH HSA PLAN
Network Name
[Network name + plan]
(In-Network Only)
[Network name + plan]
(In-Network | Out-of-Network)
[Network name + plan]
(In-Network | Out-of-Network)
Calendar Year Deductible
  • Individual
  • Family
$0 $0
$0 | $0 $0 | $0
$0 | $0 $0 | $0

Out-of-Pocket Maximum

  • Individual
  • Family
$0 $0
$0 | $0 $0 | $0
$0 | $0 $0 | $0

Preventive Care

$0 copay
$0 copay | 0%*
0% | 0%*
Primary Office Visit
$0 copay
$0 copay | 0%*
0%* | 0%*
Specialty Office Visit
$0 copay
$0 copay | 0%*
0%* | 0%*
Emergency Room
$0 copay
$0 copay | $0 copay
0%* | 0%*
Chiropractic Visit
$0 copay
$0 copay | 0%*
0%* | 0%*
Hospitalization
$0 copay
$0 copay, then 0%* | 0%*
0%* | 0%*
Outpatient Facility
$0 copay
$0 copay, then 0%* | 0%*
0%* | 0%*

PRESCRIPTION DRUGS

Retail

30-day supply

Tier 1: Generic
$0 copay
$0 copay | 0%*
$0 copay* | 0%*
Tier 2: Preferred
$0 copay
$0 copay | 0%
$0 copay | 0%
Tier 3: Non-Preferred
$0 copay
$0 copay | 0%
$0 copay | 0%

*after deductible has been met

Spousal Surcharge

Consider an In-Network Plan if:

  • You want access to both in-and out-of-network providers
  • You like having one doctor to manage your in-network care
  • You are willing to pay more to see out-of-network providers

Consider a Plus Plan if:

  • You want access to both in-and out-of-network providers
  • You like having one doctor to manage your in-network care
  • You are willing to pay more to see out-of-network providers

Consider a High Deductible Health Plan (HDHP) if:

  • You want to be able to see any provider, even a specialist, without a referral
  • You are willing to pay more to see out-of-network providers
  • You want tax-free savings on your healthcare costs
  • You want to build a savings account for future healthcare costs for you and your eligible family members
  • You want an extra way to add to your retirement savings
Dive deeper: Why Consider a HDHP?

[TITLE FOR INFORMATIVE VIDEO HERE]

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Continue to Medical Costs