Plan Details

Summary of Medical Benefits

Minimum Essential Coverage (MEC) Enhanced Plan

In-Network

Out-of-Network

Deductible

Individual

Family

N/A

Out-of-Pocket Maximum

Individual

Family

N/A

Preventive Care Services

No Charge

No Coverage

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

$25 Copay

$50 Copay

$75 Copay

No Coverage

Urgent Care Services

$75 Copay

No Coverage

Outpatient Procedures

$2,000 Benefit

No Coverage

Emergency Room Services**

Emergency Medical Transportation**

$500 Copay

$500 Benefit Limit Per Use

No Coverage

Mental Health/Chemical Dependency

Inpatient

Office Visit

No Coverage

$75 Copay

No Coverage

Labs/X-Rays

Office Visit Lab

Outpatient Lab

Outpatient X-Ray

Outpatient Major Diagnostic

No Charge

$50 Copay

$100 Copay

$500 Copay

No Coverage

Prescription Drug Coverage

Preventive

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

No Charge

$10 Copay

No Coverage

Mail Order 90 Day Supply

No Charge

No Coverage

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

No Charge

$85 Copay

No Charge

$85 Copay

No Charge

**Covered as in-network in true-emergency

Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions

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