Page 5 - VIP Mortgage Benefit Guide FINAL

Medical Plans

SUMMARY OF COVERAGE

Local Plus
Open Access Plus $2500 HDHP $5000 HDHP
Network & Plan Name $5,000 HDHP
$2500 PPO w/HSA w/HSA
**NEW**

IN NETWORK
Calendar Year
Deductibles (Indiv / Family) $2,500 / $5,000 $2,500 / $5,000* $5,000 / $10,000 $5,000 / $10,000
Preventive Care 100% Covered 100% Covered 100% Covered 100% Covered
Primary Care Visit $25 Copay 20% After deductible 20% After deductible 20% After deductible
Specialist Visit $50 Copay 20% After deductible 20% After deductible 20% After deductible
Diagnostic Exam 100% Covered 20% After deductible 20% After deductible 20% After deductible
X-Rays 100% Covered 20% After deductible 20% After deductible 20% After deductible
Complex Images 20% After deductible 20% After deductible 20% After deductible 20% After deductible
Outpatient Procedure 20% After deductible 20% After deductible 20% After deductible 20% After deductible
Inpatient Visit 20% After deductible 20% After deductible 20% After deductible 20% After deductible
Emergency Room $250 Copay 20% After deductible 20% After deductible 20% After deductible
Urgent Care $75 Copay 20% After deductible 20% After deductible 20% After deductible
$10 Copay
Pharmacy / RX (30 Day $35Copay 0% After deductible 0% After deductible 0% After deductible
Supply)
$60 Copay
Telemedicine / Virtual Visit $25 Copay $0 w/FreshBenies $0 w/FreshBenies $0 w/FreshBenies

Calendar Year
Out-of-Pocket Max (Indiv / $6,000 / $12,000 $6,250 / $12,500 $6,550 / $13,100 $6,550 / $13,100
Family)
OUT OF NETWORK
Calendar Year
Deductibles (Indiv / Family) $3,000 / $6,000 $10,000 / $20,000 $10,000 / $20,000 $10,000 / $20,000
Calendar Year
Out-of-Pocket Max (Indiv / $10,000 / $18,000 $10,000 / $20,000 $10,000 / $20,000 $10,000 / $20,000
Family)
PREMIUM PER PAYCHECK (24 Paychecks)
Employee Only $191.33 $115.71 $95.71 $80.86
Employee + Spouse $583.44 $430.49 $382.41 $341.05
Employee + Child(ren) $510.71 $374.46 $330.38 $294.88
Employee + Family $897.52 $675.98 $536.44 $480.07
*2500 HDHP deductible is NOT embedded. Members must meet the family deductible amount when covering
dependents

This booklet provides only a summary of your benefits. All services described within
2021 -2022 Employee Benefit Guide
are subject to the definitions, limitations, and exclusions set forth in each insurance 5
carrier or provider’s contract.