Compare Plans

Summary Of Medical Benefits

ACP Plan

In-Network

Out-Of-Network

Calendar year Deductible

Employee Only

Family

$2,000

$4,000

N/a

Coinsurance

10%

N/a

Out-of-Pocket Maximum

Employee Only

Family

$6,450

$12,900

N/a

Preventive Care

100% Covered

No Coverage

Office Visits

Primary Services

Specialist Services

Chiropractic Services

$35 Copay

$50 Copay

No Coverage

Hospital Services

Inpatient Care

Outpatient Facility

10%*

No Coverage

Labs and Scans

Labs and X-ray (office)

MRIs,PET, and CT Scans

$35 Copay

10%*

No Coverage

Maternity Care (Includes physician delivery fee and hospital charges)

10%*

No Coverage

Emergency Services**

Emergency Room

Emergency Medical Transportation

10%*

No Coverage

Urgent Care Services

$75 Copay

No Coverage

HealthiestYou Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, initial evaluation

Mental Health - -Psychiatrist, ongoing session

100% Covered

$50 Copay

100% Covered

$50 Copay

Mental Health/Chemical Dependency

Inpatient

Outpatient

10%*

$50 Copay

No Coverage

Retail 30 Day Supply

Mail Order 90 Day Supply

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

0%*

Not available

*After deductible

**Covered as in-network in true-emergency

PPO Plan

In-Network

Out-Of-Network

Calendar Year Deductible

Employee only

Family

$1,500

$3,000

$9,000

Coinsurance

20%

40%

Out-of-Pocket Maximum

Employee only

Family

$4,500

$13,500

$9,000

$27,000

Preventive Care

100% Covered

40%*

Office Visits

Primary Services

Specialist Services

Chiropractic Services

$25 Copay

$40 Copay

40%*

Hospital Services

Inpatient Care

Outpatient Facility

20%*

40%*

Labs and Scans

Labs and X-ray (office)

MRIs,PET,and CT Scans

20%*

40%*

Maternity Care (Includes physician delivery fee and hospital charges)

20%*

40%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

$300 Copay

20%*

40%*

Urgent Care Services

$75 Copay

40%*

HealthiestYou Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, initial evaluation

Mental Health - Psychiatrist, ongoing session

100% Covered

$40 Copay

100% Covered

$40 Copay

Mental Health/Chemical Dependency

Inpatient

Outpatient

20%*

$40 Copay

40%*

Retail 30 Day Supply

Mail Order 90 Day Supply

Prescription Drug Coverage

Generic

Preferred brand - 15 script limit per year

Non-preferred brand

Specialty

$5 Copay

$35 Copay

$50 Copay

20% Coinsurance up to $300

$45 Copay

$105 Copay

$150 Copay

Not available

*After deductible

**Covered as in-network in true-emergency

HDHP

In-Network

Out-Of-Network

Calendar Year Deductible

Employee only

Family

$3,300

$9,000

$6,000

$18,000

Coinsurance

30%

Out-of-Pocket-Maximum

Employee only

Family

$3,300

$9,000

$12,000

$36,000

Preventive Care

100% Covered

30%*

Office Visits

Primary Services

Specialist Services

Chiropractic Services

0%*

30%*

Hospital Services

Inpatient Care

Outpatient Facility

0%*

30%*

Labs and Scans

Labs and X-ray (office)

MRIs,PET, and CT Scans

0%*

30%*

Maternity Care (Includes physician delivery fee and hospital charges)

0%*

30%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

0%*

30%*

Urgent Care Services

0%*

30%*

HealthiestYou Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, initial evaluation

Mental Health - Psychiatrist, ongoing session

$45 fee applies until deductible is met, then 0%*

$75 fee applies until deductible is met, then 0%*

$85 fee applies until deductible is met, then 0%*

$200 fee applies until deductible is met, then 0%*

$95 fee applies until deductible is met, then 0%*

$45 fee applies until deductible is met, then 0%*

$75 fee applies until deductible is met, then 0%*

$85 fee applies until deductible is met, then 0%*

$200 fee applies until deductible is met, then 0%*

$95 fee applies until deductible is met, then 0%*

Mental Health/Chemical Dependency

Inpatient

Outpatient

0%*

30%*

Retail 30 Day Supply

Mail Order 90 Day Supply

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

0%*

Not available

MEC Preventive

In-Network

Out-Of-Network

Calendar Year Deductible

Employee Only

Family

N/a

Coinsurance

N/a

Out-Of-Pocket Maximum

Employee Only

Family

N/a

Preventive Care

100% Covered

No Coverage

Office Visits

Primary Services

Specialist Services

Chiropractic Services

No Coverage

Hospital Services

Inpatient Care

Outpatient Facility

No Coverage

Labs and Scans

Labs and X-ray (office)

MRIs,PET, and CT Scans

No Coverage

Maternity Care (Includes physician delivery fee and hospital charges)

No Coverage

Emergency Services

Emergency Room

Emergency Medical Transportation

No Coverage

Urgent Care Services

No Coverage

HealthiestYou Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, initial evaluation

Mental Health - Psychiatrist, ongoing session

100% Covered

$40 Copay

100% Covered

$40 Copay

Mental Health / Chemical Dependency

Inpatient

Outpatient

No Coverage

Retail 30 Day Supply

Mail Order 90 day Supply

Prescription Drug Coverage

Preventive

Generic

Preferred brand

Non-preferred brand

Specialty

100% Covered

Not available

MEC Plus Plan

In-Network

Out-Of-Network

Calendar Year Deductible

Employee Only

Family

N/a

Coinsurance

N/a

Out-Of-Pocket Maximum

Employee Only

Family

N/a

Preventive Care

100% Covered

No Coverage

Office Visits

Primary Services - 5 visit limit per year

Specialist Services - 5 visit limit per year

Chiropractic Services

$25 Copay

$40 Copay

No Coverage

Hospital Services

Inpatient Care

Outpatient Facility

No Coverage

Labs and Scans

Labs and X-ray (office) - 3 visit limit per year

MRIs,PET, and CT Scans

$40 Copay

No Coverage

Maternity Care (Includes physician delivery fee and hospital charges)

No Coverage

Emergency Services

Emergency Room

Emergency Medical Transportation

No Coverage

Urgent Care Services - 5 visit limit per year

$75 Copay

No Coverage

HealthiestYou Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, initial evaluation

Mental Health - Psychiatrist, ongoing session

100% Covered

$40 Copay

100% Covered

$40 Copay

Mental Health / Chemical Dependency

Inpatient

Outpatient

No Coverage

Retail 30 Day Supply

Mail Order 90 day Supply

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

$5 Copay

$40 Copay

Not available

$12.50 Copay

$100 Copay

Not available

**15 combined prescription limit per year including retail and mail.

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