Page 10 - HR_10930_2022_Benefits_Book_v6_pages - With Links for Flipbook

Medical Plan Comparison

Open Access Plus
Consumer Choice HSA Plan Open Access Plus In-Network
(HSA) (PPO)
(EPO)
In-Network Out-of-Network In-Network Out-of-Network In-Network Only
HSA Employer
Contribution $250/$500 $0 $0
Individual/Family
Annual Deductible $1,500 / $3,000 $500/$1,000 $0
Individual/Family

Annual Out-of- $3,400 / $6,800 $2,000 / $4,000 $2,500 / $5,000
pocket Maximum Deductible, co-pays, coinsurance apply Deductible, co-pays, coinsurance apply Co-pays only apply
Individual/Family medical and prescriptions medical only medical only
Lifetime Plan Unlimited Unlimited Unlimited
Maximum Plan pays 100% after deductible $20 Co-pay after deductible $20 Co-pay
Plan pays 80%
Plan pays 70%
PHYSICAL WELL-BEING Well-Child Care Plan pays 100% after deductible $20 Co-pay after deductible $20 Co-pay
PCP Office Visit
after deductible
Plan pays 80%
Plan pays 70%
Specialist Visit
after deductible
Plan pays 80%
Plan pays 70%
No Co-pay
No Co-pay
No Co-pay
after deductible
after deductible
Plan pays 70%
Plan pays 80%
Routine GYN Exams
Plan pays 70%
Routine Adult No Co-pay after deductible No Co-pay after deductible No Co-pay
Plan pays 80%
Physicals No Co-pay after deductible No Co-pay after deductible No Co-pay
Chiropractic & Plan pays 100% Plan pays 80% Plan pays 70%
Acupuncture Services after deductible after deductible $20 Co-pay after deductible $20 Co-pay
Plan pays 100% after Plan pays 80% Plan pays 90% Plan pays 70%
Lab and X-Rays No Co-pay
deductible after deductible after deductible after deductible
Advanced Radiology Plan pays 100% after Plan pays 80% Plan pays 90% Plan pays 70% $20 Co-pay
Imaging deductible after deductible after deductible after deductible
Inpatient Plan pays 100% Plan pays 80% Plan pays 90% Plan pays 70%
Hospital Services after deductible after deductible after deductible after deductible $500 Co-pay
Plan pays 100% Plan pays 80% Plan pays 90% Plan pays 70%
Outpatient Surgery $250 Co-pay
after deductible after deductible after deductible after deductible
MDLive Plan pays 100% after deductible $20 Co-pay $20 Co-pay
Urgent Care Facility Plan pays 100% after deductible $20 Co-pay $20 Co-pay
$100 Co-pay,
Emergency Room Plan pays 100% after deductible $100 Co-pay, waived if admitted
waived if admitted

Mental Health Plan pays 100% Plan pays 80% Plan pays 90% Plan pays 70%
Inpatient Care after deductible after deductible after deductible after deductible $500 Co-pay

Mental Health Plan pays 100% Plan pays 80% $20 Co-pay Plan pays 70% $20 Co-pay
Office Visit after deductible after deductible after deductible
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