Page 5 - Benefits Guide
P. 5
Medical Plan Details
[Carrier] [Carrier]
[Plan 1] [Plan 2]
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
[Embedded/Non-embedded]* [Embedded/Non-embedded]*
Individual [$X,XXX] [$X,XXX] [$X,XXX] [$X,XXX]
Family [$X,XXX] [$X,XXX] [$X,XXX] [$X,XXX]
Out-of-Pocket Maximum (includes deductible)
[Embedded/Non-embedded]* [Embedded/Non-embedded]*
Individual [$X,XXX] [$X,XXX] [$X,XXX] [$X,XXX]
Family [$X,XXX] [$X,XXX] [$X,XXX] [$X,XXX]
Physician Ofice Visits
Preventive Care Covered at 100% Covered at 100%
Primary Care Visit
Specialist Visit
Telemedicine
Urgent Care
Hospital Services
Inpatient
Outpatient
Emergency Room
Prescription Drugs
Please note: for the HSA qualiied plans, all prescription drug expenses are subject to the medical deductible. Once you meet
your deductible, copays or coinsurance will apply.
Generic
Preferred Brand Formulary
Non-Preferred Brand
Formulary
Mail Order
Generic
Preferred Brand Formulary
Non-Preferred Brand
Formulary
[Customize as needed]
* Embedded and non-embedded plans are important to consider if you are going to cover family members on your plan.
With family coverage in non-embedded plans the individual deductible and out-of-pocket maximum will never apply. You or a combination of
your family members must satisfy the full family deductible and out-of-pocket maximum before the plan begins covering your eligible expenses.
With family coverage in embedded plans, the individual deductible and out-of-pocket maximum still applies to each individual on the plan. You
can satisfy the individual limit and the plan begins covering your eligible expenses. Additionally, once a combination of family members satisies
the full family deductible and out-of-pocket maximum, the plan begins covering all family members eligible expenses.
This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In
the event there is a discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your
SPD will prevail.
[Client Name] 5 5
[Carrier] [Carrier]
[Plan 1] [Plan 2]
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
[Embedded/Non-embedded]* [Embedded/Non-embedded]*
Individual [$X,XXX] [$X,XXX] [$X,XXX] [$X,XXX]
Family [$X,XXX] [$X,XXX] [$X,XXX] [$X,XXX]
Out-of-Pocket Maximum (includes deductible)
[Embedded/Non-embedded]* [Embedded/Non-embedded]*
Individual [$X,XXX] [$X,XXX] [$X,XXX] [$X,XXX]
Family [$X,XXX] [$X,XXX] [$X,XXX] [$X,XXX]
Physician Ofice Visits
Preventive Care Covered at 100% Covered at 100%
Primary Care Visit
Specialist Visit
Telemedicine
Urgent Care
Hospital Services
Inpatient
Outpatient
Emergency Room
Prescription Drugs
Please note: for the HSA qualiied plans, all prescription drug expenses are subject to the medical deductible. Once you meet
your deductible, copays or coinsurance will apply.
Generic
Preferred Brand Formulary
Non-Preferred Brand
Formulary
Mail Order
Generic
Preferred Brand Formulary
Non-Preferred Brand
Formulary
[Customize as needed]
* Embedded and non-embedded plans are important to consider if you are going to cover family members on your plan.
With family coverage in non-embedded plans the individual deductible and out-of-pocket maximum will never apply. You or a combination of
your family members must satisfy the full family deductible and out-of-pocket maximum before the plan begins covering your eligible expenses.
With family coverage in embedded plans, the individual deductible and out-of-pocket maximum still applies to each individual on the plan. You
can satisfy the individual limit and the plan begins covering your eligible expenses. Additionally, once a combination of family members satisies
the full family deductible and out-of-pocket maximum, the plan begins covering all family members eligible expenses.
This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In
the event there is a discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your
SPD will prevail.
[Client Name] 5 5
