Page 7 - 2021 Vocon Benefits Guide

Medical Plan Comparison

PPO Plan HSA Plan

Plan Provision In-Network Out-of-Network In-Network Out-of-Network

Annual Deductible
(Individual/Family) – $250/$500 $750/$1,500 $3,000/$6,000 $9,000/$18,000
CALENDAR YEAR
Out-of-Pocket Maximum (Includes $2,200/$4,400 $6,600/$13,200 $4,000/$8,000 $12,000/$24,000
Deductible) - CALENDAR YEAR
Preventive Care No charge 50% coinsurance* No charge 30% coinsurance*
Primary Physician Office Visit $20/visit 50% coinsurance* 0% coinsurance* 30% coinsurance*

Specialist Office Visit $40/visit 50% coinsurance* 0% coinsurance* 30% coinsurance*
X-Ray and Lab No charge 50% coinsurance* 0% coinsurance* 30% coinsurance*
Inpatient Hospital Services 20% coinsurance* 50% coinsurance* 0% coinsurance* 30% coinsurance*

Outpatient Hospital Services 20% coinsurance* 50% coinsurance* 0% coinsurance* 30% coinsurance*
Urgent Care $75/visit 50% coinsurance 0% coinsurance* 30% coinsurance*

$300/visit then 20% $300/visit then
Emergency Room Care 0% coinsurance* 0% coinsurance*
coinsurance* 20% coinsurance*
Prescription Drugs

Retail Prescription Drugs
(30-day supply)
• Generic $10 copay $10 copay*
• Brand Preferred $40 copay 50% $40 copay* 50%
• Brand Non-preferred $70 copay coinsurance $70 copay* coinsurance*
• Specialty 25% up to $350 max* 25% up to $350 max*

Mail Order Prescription Drugs (90-
day supply)
• Generic $20 copay $20 copay*
• Brand Preferred $120 copay Not $120 copay* Not
• Brand Non-preferred $210 copay Covered $210 copay* Covered
• Specialty 25% up to $350 max* 25% up to $350 max*

Note: This is a summary of your coverage only. Please refer to your summary plan description for the full scope of coverage. In-
network services are based on negotiated charges; out-of-network services are based on reasonable and customary (R&C)
charges.
*After deductible is satisfied.

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