Page 5 - Guide
P. 5
Plan Details
[Carrier] [Carrier] [Carrier] [Carrier]
[Plan 1] [Plan 2] [Plan 3] [Plan 4]
In-Network In-Network In-Network In-Network
Calendar Year Deductible
Embedded—no Embedded—no Not embedded—family Embedded—no
one individual must one individual must ded applies if one or one individual must
meet more than the meet more than the more dependents are meet more than the
individual limit individual limit covered individual limit
Individual [$X,XXX] [$X,XXX] [$X,XXX] [$X,XXX]
Family [$X,XXX] [$X,XXX] [$X,XXX] [$X,XXX]
Out-of-Pocket Maximum
Individual [$X,XXX] [$X,XXX] [$X,XXX] [$X,XXX]
Family [$X,XXX] [$X,XXX] [$X,XXX] [$X,XXX]
Physician Ofice Visits
Wellness/Preventive Covered at 100% Covered at 100% Covered at 100% Covered at 100%
Primary Care
Specialist
Urgent Care
Hospital Services
Inpatient
Outpatient
Emergency Room
Ambulance
Chiropractic Care—30 visits
* The ofice visit copay applies when the physician bills for an ofice visit. Labs and non-major diagnostics are covered at 100%. All other services
are subject to ded/coinsurance. Examples of these other services include but are not limited to major diagnostics (CT, PET, MRI scans, etc.),
nuclear medicine, therapeutic scopic procedures, surgery, therapeutic treatments, allergy injections, etc.
** Exceptions: major diagnostics (CT, PET, MRI nuclear medicine, etc.) which are deductible/coinsurance
For out-of-network coverage details, please refer to your summary plan description (SPD) or an oficial plan
document.
[Client Name] 5
[Carrier] [Carrier] [Carrier] [Carrier]
[Plan 1] [Plan 2] [Plan 3] [Plan 4]
In-Network In-Network In-Network In-Network
Calendar Year Deductible
Embedded—no Embedded—no Not embedded—family Embedded—no
one individual must one individual must ded applies if one or one individual must
meet more than the meet more than the more dependents are meet more than the
individual limit individual limit covered individual limit
Individual [$X,XXX] [$X,XXX] [$X,XXX] [$X,XXX]
Family [$X,XXX] [$X,XXX] [$X,XXX] [$X,XXX]
Out-of-Pocket Maximum
Individual [$X,XXX] [$X,XXX] [$X,XXX] [$X,XXX]
Family [$X,XXX] [$X,XXX] [$X,XXX] [$X,XXX]
Physician Ofice Visits
Wellness/Preventive Covered at 100% Covered at 100% Covered at 100% Covered at 100%
Primary Care
Specialist
Urgent Care
Hospital Services
Inpatient
Outpatient
Emergency Room
Ambulance
Chiropractic Care—30 visits
* The ofice visit copay applies when the physician bills for an ofice visit. Labs and non-major diagnostics are covered at 100%. All other services
are subject to ded/coinsurance. Examples of these other services include but are not limited to major diagnostics (CT, PET, MRI scans, etc.),
nuclear medicine, therapeutic scopic procedures, surgery, therapeutic treatments, allergy injections, etc.
** Exceptions: major diagnostics (CT, PET, MRI nuclear medicine, etc.) which are deductible/coinsurance
For out-of-network coverage details, please refer to your summary plan description (SPD) or an oficial plan
document.
[Client Name] 5
