| ACCESS TO CARE HIGHLIGHTS |
Network |
Out of Network |
|
|
| Network |
PPO network + non-network providers |
PPO network providers only |
HDHP network providers only |
| Access to doctors, hospitals, etc. |
Visit any doctor you choose |
Visit any doctor in the PPO network |
Visit any doctor in the PPO network |
| Virtual care |
$0 (through Teladoc) or copay/coinsurance for doctor/specialist office visit below.
|
$0 (through Teladoc) or copay/coinsurance for doctor/specialist office visit below. |
$0 (through Teladoc) or copay/coinsurance for doctor/specialist office visit below. |
| Mental health |
Need copy here |
|
|
| MEDICAL BENEFITS |
Network |
Out of Network |
|
|
| Deductible: Individual Network |
"None" or $ w/commas ($1,500) |
"None" or $ w/commas ($1,500) |
"None" or $ w/commas ($1,500) |
"None" or $ w/commas ($1,500) |
| Deductible: Family Network |
"None" or $ w/commas ($1,500) |
"None" or $ w/commas ($1,500) |
"None" or $ w/commas ($1,500) |
"None" or $ w/commas ($1,500) |
| PCP Office Visit |
$ w/commas or % |
% |
$ w/commas or % |
$ w/commas or % |
| Specialist Office Visit |
$ w/commas or % |
% |
$ w/commas or % |
$ w/commas or % |
| Lab Work |
$ w/commas or % |
% |
$ w/commas or % |
$ w/commas or % |
| Outpatient surgery |
$ w/commas or % |
% |
$ w/commas or % |
$ w/commas or % |
| Inpatient hospitalization |
$ w/commas or % |
% |
$ w/commas or % |
$ w/commas or % |
| Teladoc |
$ w/commas |
|
$ w/commas |
$ w/commas |
| Acupuncture |
$ or % |
% |
$ or % |
$ or % |
| Chiropractic |
$ or % |
% |
$ or % |
$ or % |
| PHARMACY BENEFITS |
Network |
Out of Network |
|
|
| Pharmacy Deductible |
"None" or $ and commas ($1,500) |
"No charge" or $x or 0%/prescription |
"No charge" or $x or 0%/prescription |
"No charge" or $x or 0%/prescription |
| Tier 1 drugs |
"No charge" or $x or 0%/prescription |
"No charge" or $x or 0%/prescription |
"No charge" or $x or 0%/prescription |
"No charge" or $x or 0%/prescription |
| Tier 2 drugs |
"No charge" or $x or 0%/prescription |
"No charge" or $x or 0%/prescription |
"No charge" or $x or 0%/prescription |
"No charge" or $x or 0%/prescription |
| Tier 3 drugs |
"No charge" or $x or 0%/prescription |
"No charge" or $x or 0%/prescription |
"No charge" or $x or 0%/prescription |
"No charge" or $x or 0%/prescription |
| Tier 4 drugs |
"No charge" or $x or 0%/prescription |
"No charge" or $x or 0%/prescription |
"No charge" or $x or 0%/prescription |
"No charge" or $x or 0%/prescription |
