Consumer Driven Health Plan
Benefits at a Glance
BENEFIT DESCRIPTION |
YOU PAY |
|
In-Network |
Out-of-Network |
|
Preventive Care |
||
Annual Routine Physical Exam (age 3 or older) |
Nothing |
50% after deductible is met* |
Adult Routine Immunizations & Tests |
Nothing |
50% after deductible is met* |
Well Child Care (through age 2) |
Nothing |
50% after deductible is met* |
Nothing |
50% after deductible is met* |
|
Inpatient Hospital Care (precertification required) |
||
Maternity |
20% after deductible is met |
50% after deductible is met* |
Medical/Surgery Room and Board |
20% after deductible is met |
50% after deductible is met* |
Mental Health/Substance Abuse Room & Board Other Services and Supplies |
|
|
Outpatient Hospital Care |
||
Medical/surgical |
20% after deductible is met |
50% after deductible is met* |
Emergency Medical |
20% after deductible is met |
20% after deductible is met* |
Chiropractic Care |
||
Initial office visit and 12 office visits per calendar year when rendered on the same day as covered manipulations |
20% after deductible is met |
50% after deductible is met* |
Manipulations (12 per calendar year) |
20% after deductible is met |
50% after deductible is met* |
Physician Care |
||
Office or virtual visits |
20% after deductible is met |
50% after deductible is met* |
Telehealth professional services for minor acute conditions |
10% after deductible is met |
All charges |
X-rays, other diagnostic services |
20% after deductible is met |
50% after deductible is met* |
Laboratory Services |
20% after deductible is met |
50% after deductible is met* |
Maternity Care (complete) |
20% after deductible is met |
50% after deductible is met* |
Accidental Injury (nonsurgical care, simple laceration repair and immobilization of a sprain, strain, or fracture) |
20% after deductible is met |
50% after deductible is met* |
Surgery |
20% after deductible is met |
50% after deductible is met* |
Mental Health and Substance |
||
Office visit |
20% after deductible is met |
50% after deductible is met* |
Outpatient telemental or virtual visits |
10% after deductible is met |
50% after deductible is met* |
Other diagnostic services |
20% after deductible is met |
50% after deductible is met* |
Laboratory Services |
20% after deductible is met |
50% after deductible is met* |
Prescription Drugs |
Network |
Non-Network |
Retail Pharmacy |
1st and 2nd fill: Note: You may purchase up to a 90-day supply (84-day minimum) of covered drugs and supplies at a CVS Caremark® Pharmacy or Longs Drugs through our Maintenance Choice Program. You will pay the applicable mail order copayment for each prescription purchased. |
Full cost at time of purchase |
Mail Order Program |
90-day supply: $20 generic/$90 Formulary brand/$125 Non-Formulary brand (after deductible is met) |
|
Specialty drugs (requires prior approval) - We utilize the NALC's Advanced Control Specialty Formulary. |
|
|
Deductible | ||
In-Network | Out-of-Network | |
CDHP |
Self - $2,000 |
Self - $4,000 Self Plus One - $8,000 Self and Family - $8,000 |
Catastrophic Limits |
||
Medical/Surgical/Mental health and substance abuse care |
In-Network providers/facilities, preferred network pharmacies or mail order pharmacy out-of-pocket maximum: Per person: $6,600 Out-of-Network providers/facilities out-of-pocket maximum: Per person: $12,000 |
|
*In addition, you are responsible for the difference, if any, between the Plan allowance and the billed amount. |