Benefit Summary
| Plan Name | Medical HDHP Lower Deductible $2000 (Non-Embedded) | |
| Description | All Employees | |
| Carrier | UMR | |
| Policy Type | Medical POS (2-Tier) | |
| Effective Dates | 1/1/2023 to 1/1/2025 | |
| Benefit Attributes - All Employees | POS In-Network | POS Out-of-Network |
| Emergency Services | ||
| Emergency Room | 90% after deductible | 90% after network deductible |
| General Plan Information | ||
| Annual Out-of-Pocket Limit/Individual | $3,000 | $6,000 |
| Office Visit/Exam | 90% after deductible | 70% after deductible |
| Annual Out-of-Pocket Limit/Family | $6,000 | $12,000 |
| Annual Deductible/Individual | $2,000 | $4,000 |
| Outpatient Specialist Visit | 90% after deductible | 70% after deductible |
| Coinsurance | 90% | 70% |
| Annual Deductible/Family | $4,000 | $8,000 |
| Deductible Included in Out-of-Pocket Limits | Yes | Yes |
| Inpatient Hospital Services | ||
| Inpatient Hospitalization | 90% after deductible | 70% after deductible |
| Diagnostic X-Ray and Lab Tests | 90% after deductible | 70% after deductible |
| Outpatient Facility Charges | 90% after deductible | 70% after deductible |
| Mail Order | ||
| Preferred Specialty | 90% (Preventive drugs: 100% no deductible) | Not covered |
| Brand (Formulary/Preferred) | 90% (Preventive drugs: 100% no deductible) | 30% of Contracted Rate (Preventive drugs: 10% of contracted rate) |
| Non-preferred Specialty | 85% (Preventive drugs: 100% no deductible) | Not covered |
| Preferred Generic | N/A | N/A |
| Generic | 90% (Preventive drugs: 100% no deductible) | 30% of Contracted Rate (Preventive drugs: 10% of contracted rate) |
| Brand (Non-Formulary/Non-preferred) | 85% (Preventive drugs: 100% no deductible) | 30% of Contracted Rate (Preventive drugs: 10% of contracted rate) |
| Number of Days Supply for Mail Order | 90 days | 90 days |
| Maternity Care | ||
| Pregnancy and Maternity Care (Pre-Natal Care) | 100% no deductible for Prenatal; Delivery: 90% after deductible | 70% after deductible |
| Mental Health Benefits | ||
| Inpatient Care | 90% after deductible | 70% after deductible |
| Outpatient Care | 90% after deductible | 70% after deductible |
| Other Services and Supplies | ||
| Chiropractic Services | Covered | Covered |
| Outpatient Rehabilitative Therapy Services | ||
| Speech | 90% after deductible | 70% after deductible |
| Physical | 90% after deductible | 70% after deductible |
| Occupational | 90% after deductible | 70% after deductible |
| Outpatient Services | ||
| Pediatric Vision | Not covered | Not covered |
| Diagnostic X-Ray and Lab Tests | 90% after deductible | 70% after deductible |
| Well-Child Care | 100% no deductible | 70% after deductible |
| Immunizations | 100% no deductible | 70% after deductible |
| Adult Periodic Exams with Preventive Tests | 100% no deductible | 70% after deductible |
| Pediatric Dental | Not covered | Not covered |
| Prescription Drug Benefits | ||
| Generic | 90% (Preventive drugs: 100% no deductible) | 30% of Contracted Rate (Preventive drugs: 10% of contracted rate) |
| Brand (Non-Formulary/Non-preferred) | 85% (Preventive drugs: 100% no deductible) | 30% of Contracted Rate (Preventive drugs: 10% of contracted rate) |
| Brand (Formulary/Preferred) | 90% (Preventive drugs: 100% no deductible) | 30% of Contracted Rate (Preventive drugs: 10% of contracted rate) |
| Preferred Generic | N/A | N/A |
| Preferred Specialty | 90% (Preventive drugs: 100% no deductible) | Not covered |
| Number of Days Supply | 34 days | 34 days |
| Non-preferred Specialty | 85% (Preventive drugs: 100% no deductible) | Not covered |
| Prescription Drug Deductible | Subject to medical deductible | Subject to medical deductible |
| Injectables | ||
| Substance Abuse | ||
| Inpatient Hospitalization | 90% after deductible | 70% after deductible |
| Outpatient Services | 90% after deductible | 70% after deductible |
| Urgent Care | ||
| Urgent Care Facility | 90% after deductible | 70% after deductible |