Page 10 - Franklin Madison 2021 Benefits Guide

Medical Comparison Chart

Consumer Choice with HSA POS Enhanced POS Basic
Beneit In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Providers
Providers
Providers
Providers
Providers
Providers
Annual Deductibles
Individual $1,400 $3,000 $550 $2,000 $1,500 $4,000
Family $2,800 $5,000 $1,850 $4,000 $3,000 $8,000
Out-of-Pocket Maximum (Includes deductible amount)
Individual $3,000 $6,000 $1,500 $3,000 $2,500 $6,000
Family $6,000 $10,000 $3,000 $6,000 $5,000 $12,000
HSA Employer Funding
Individual: up to $600 N/A N/A
Family: up to $1,200
Oice Visits
Primary 90% after 70% after $25 copay 70% after $30 copay 60% after
deductible
deductible
deductible
deductible
Specialist 90% after 70% after $40 copay 70% after $40 copay 60% after
deductible
deductible
deductible
deductible
Preventive Services
Routine 70% after
preventative No charge deductible No charge Not covered No charge Not covered
service
Urgent Care
90% after deductible $50 copay (waived if admitted) $50 copay (waived if admitted)
Emergency Services
Emergency 90% after deductible $150 copay (waived if admitted) $150 copay (waived if admitted)
Room
Ambulance 90% after deductible 90% after deductible 80% after deductible
Bloodwork/ X-ray Facility
90% after 70% after 100% 70% after 100% 60% after
deductible deductible deductible deductible

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