Page 6 - Mitsubishi-2022-Benefit Guide-MCCFC-MCA Golf-V14(JO)-LRI

In-Network Medical and pharmacy coverage

BCBST – BCBST –
Medical Plan Provisions* Sharp – HMO Plan Kaiser – HMO Plan
Enhanced Plan Standard Plan
Annual Deductible $750/$1,500 $1,500/$3,000 $0/$0 $0/$0
(Individual/Family)

Plan Coinsurance 80% 80% N/A N/A
(copays for services) (copays for services)
Out-of-Pocket Maximum $3,000/$6,000 $4,000/$7,000 $3,500/$7,000 $1,500/$3,000
(Includes Deductible)

Telemedicine (PhysicianNow) $0 copay $0 copay Varies depending on $0 copay
carrier utilized
Primary Care Provider
Office Visit** $20 copay $25 Copay $25 copay $20 copay

Urgent Care Visit $25 copay $35 copay $35 copay $20 copay
Specialist Office Visit** $30 copay $50 copay $35 copay $20 copay
X-Ray and Lab 20% 20% $0 copay $10 per encounter

Inpatient Hospital Services 20% $250 copay*** $500 per day $0 copay
(3-day max)
Outpatient Hospital Services 20% $200 copay*** $500 per procedure $20 per procedure

Emergency Room 20% $250 copay $100 per visit $50 per visit
Retail pharmacy (up to a 30-day supply)
Generic $10 copay $15 copay $15 copay $15 copay

Formulary $30 copay $35 copay $35 copay $35 copay
Non-Formulary $50 copay $55 copay $50 copay $35 copay

*In-Network benefits. Embedded deductibles and out-of-pocket maximums.
**Primary Care Physician/Specialty Care Physician copays (if applicable)
***Then subject to deductible and coinsurance

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