Page 11 - Trident 2022 Flipbook
P. 11
MEDICAL COVERAGE PLAN C
Plan C HDHP with HSA
Plan Provision
In-Network Out-of-Network
If you enroll in our Medical Plan C, the Rangers will contribute $250 annually
Company Contribution to HSA
into your Health Savings Account (H.S.A.); over 24 pay periods.
Annual Deductible
Individual $1,400 Combined with In-Network
Family $2,800 Combined with In-Network
Out-of-Pocket Maximum (Includes Deductible)
Individual None $1,500
Family None $3,000
Lifetime Maximum Unlimited
Preventive Care 100% 80% after Deductible
Primary Physician Office Visit 100% after Deductible 80% after Deductible
Specialist Office Visit 100% after Deductible 80% after Deductible
X-Ray and Lab 100% after Deductible 80% after Deductible
Inpatient Hospital Services 100% after Deductible 80% after Deductible
Outpatient Hospital Services 100% after Deductible 80% after Deductible
Urgent Care 100% after Deductible 80% after Deductible
Emergency Room Care 100% after Deductible
The above is a summary of this benefit option.
Click here for more detailed information on this available benefit option.
2022 Trident Benefit Guide Page 11
