Page 8 - 2023 SpeciatlyCare Benefit Guide

2023 Benefits Guide

Medical Plan Provisions

SpecialtyCare offers a choice of medical plan options so you can choose the plan that best meets your needs
and those of your family.

Plan Provisions PPO HDHP
In-Network Out-of-Network In-Network Out-of-Network
Company Contribution to HSA N/A $500 Single / $1,000 Family
(Individual/Family)
Annual Deductible $2,000/$4,000 $4,000/$8,000 $3,000/$6,000 $6,000/$12,000
(Individual/Family Maximum)
Deductibles are met at the individual level; however, once the family deductible is satisfied,
deductibles for all other covered family members are considered met.
Out-of-Pocket Maximum $7,000/$14,000 $10,000/$20,000 $4,200/$8,400 $10,000/$20,000
(Includes Deductible)
Lifetime Maximum Unlimited
Preventative Care 100% 50% 100% 50%

Primary Physician Office Visit $45 co-pay 50%* 80%* 50%*

Specialist Office Visit $60 co-pay 50%* 80%* 50%*
Telehealth $45 co-pay 50%* $55*** N/A
X-Ray and Lab 100% 50%* 80%* 50%*

Inpatient Hospital Services 70%* 50%* 80%* 50%*

Outpatient Hospital Services 70%* 50%* 80%* 50%*
Urgent Care $60 co-pay 50%* 80%* 50%*
Emergency Room Care 70%* 80%*

Retail Prescription Drugs
(30-day supply) RX Deductible $150 / $400**
(Individual /Family)
• Generic $20 copay 50%* $20 co-pay* 50%*
• Brand Preferred $40 copay** $40 co-pay*
• Brand Non-preferred $70 copay** $70 co-pay*

Mail Order Prescription Drugs
(90-day supply)
• Generic $50 $50*
• Brand Preferred $100 $100*
• Brand Non-preferred $175 $175*
*After the deductible is met. **RX deductible only applies to Brand Preferred and Brand Non-Preferred drugs. ***Cost can change.
Note: This is a summary of coverage only. Please refer to the summary of benefits coverage for complete
information. In-network services are based on negotiated charges; out-of-network services are based on
Reasonable and Customary (R&C) charges.

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