Page 4 - Summit BHC 2022 Benefits Guide St. Joseph

Medical

Plan Year: 12/1/2021-11/30/2021

In-Network Out-of-Network
Plan Year Deductible (Embedded)
Individual $750 $1,500
Family $2,250 $4,500
Coinsurance Maximum
Individual $2,500 $4,000
Family $7,500 $12,000
Hospital Services
Inpatient 80% after deductible 60% after deductible
Outpatient 80% after deductible 60% after deductible
Emergency Room $100 copay
Oice Visits
Preventive Care Covered 100% 60% after deductible
Virtual Visit $5 or $10 copay 60% after deductible
Primary Care $25 copay 60% after deductible
Specialist $45 copay 60% after deductible
Urgent Care $25 copay
Prescription Drug Coverage
Retail—34-Day Supply
Tier 1 $20 copay
Tier 2 $35 copay
Tier 3 $60 copay
Mail Order—90-Day Supply Not covered
Tier 1 $50 copay
Tier 2 $87.50 copay
Tier 3 $150 copay

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