Page 7 - 2020 BH Management Benefits Guide
P. 7
Plan Details
Traditional PPO Plan HDHP
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $2,000 $3,000 $3,500 $7,000
Family $5,000 $9,000 $7,000 $14,000
Out-of-Pocket Maximum
Individual $5,000 $8,000 $7,000 $14,000
Family $14,000 $16,000 $14,000 $28,000
Physician Oice Visits
Preventive Care 100% no deductible 50% after deductible 100% no deductible 50% after deductible
Primary Care $25 copay 50% after deductible $30 copay 50% after deductible
Specialist $50 copay 50% after deductible $60 copay 50% after deductible
Chiropractic Care $25 copay 50% after deductible $30 copay 50% after deductible
Hospital Services
Inpatient 20% after deductible 50% after deductible 30% after deductible 50% after deductible
Outpatient 20% after deductible 50% after deductible 30% after deductible 50% after deductible
Emergency Room $300 copay $300 copay 30% after deductible 30% after deductible
Urgent Care $55 copay 50% after deductible $60 copay 50% after deductible
Prescription Drugs
Retail—Supply Limit* Non-maintenance drugs: 30-day supply;
Maintenance drugs: 90-day supply
Tier 1 $7 copay $10 copay
Tier 2 $25 copay Reimbursement up to $25 copay Reimbursement up to
Tier 3 $45 copay the maximum allowable $50 copay the maximum allowable
Specialty—Must Use CVS fee, less the in-network fee, less the in-network
Preferred Specialty $100 copay copay amount $100 copay copay amount
Non-Preferred Specialty $200 copay $200 copay
Mail Order—Supply Limit Non-maintenance drugs: 30-day supply;
Maintenance drugs: 90-day supply
Tier 1 $17.50 copay Reimbursement up to $25 copay Reimbursement up to
Tier 2 $62.50 copay the maximum allowable $62.50 copay the maximum allowable
fee, less the in-network
fee, less the in-network
Tier 3 $112.50 copay copay amount $125 copay copay amount
* Specialty Pharmacy is not covered under mail order prescriptions.
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.
2020 Benefits Guide 7
Traditional PPO Plan HDHP
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $2,000 $3,000 $3,500 $7,000
Family $5,000 $9,000 $7,000 $14,000
Out-of-Pocket Maximum
Individual $5,000 $8,000 $7,000 $14,000
Family $14,000 $16,000 $14,000 $28,000
Physician Oice Visits
Preventive Care 100% no deductible 50% after deductible 100% no deductible 50% after deductible
Primary Care $25 copay 50% after deductible $30 copay 50% after deductible
Specialist $50 copay 50% after deductible $60 copay 50% after deductible
Chiropractic Care $25 copay 50% after deductible $30 copay 50% after deductible
Hospital Services
Inpatient 20% after deductible 50% after deductible 30% after deductible 50% after deductible
Outpatient 20% after deductible 50% after deductible 30% after deductible 50% after deductible
Emergency Room $300 copay $300 copay 30% after deductible 30% after deductible
Urgent Care $55 copay 50% after deductible $60 copay 50% after deductible
Prescription Drugs
Retail—Supply Limit* Non-maintenance drugs: 30-day supply;
Maintenance drugs: 90-day supply
Tier 1 $7 copay $10 copay
Tier 2 $25 copay Reimbursement up to $25 copay Reimbursement up to
Tier 3 $45 copay the maximum allowable $50 copay the maximum allowable
Specialty—Must Use CVS fee, less the in-network fee, less the in-network
Preferred Specialty $100 copay copay amount $100 copay copay amount
Non-Preferred Specialty $200 copay $200 copay
Mail Order—Supply Limit Non-maintenance drugs: 30-day supply;
Maintenance drugs: 90-day supply
Tier 1 $17.50 copay Reimbursement up to $25 copay Reimbursement up to
Tier 2 $62.50 copay the maximum allowable $62.50 copay the maximum allowable
fee, less the in-network
fee, less the in-network
Tier 3 $112.50 copay copay amount $125 copay copay amount
* Specialty Pharmacy is not covered under mail order prescriptions.
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.
2020 Benefits Guide 7
