Page 7 - 2018-19 MYNEXUS Benefits Guide

myNEXUS
Plan Details

Choice Care PPO/Choice POS
Base Plan Buy-Up Plan
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Embedded Embedded
Deductible
Individual $4,500 $13,500 $2,800 $8,400
Family $9,000 $27,000 $5,600 $16,800
Out-of-Pocket Maximum Embedded Embedded
Individual $6,350 $19,050 $5,000 $15,000
Family $12,700 $38,100 $10,000 $30,000
Physician Office Visits
Primary Care 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Specialist 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Preventive 100% no deductible 50% after deductible 100% no deductible 50% after deductible
Urgent Care 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Hospital Services
Inpatient 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Outpatient 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Emergency Room 70% after deductible 80% after deductible
Therapy 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Limitations 60 visits combined 10 visits combined 60 visits combined 10 visits combined
Prescription Drugs
Retail—Supply Limit 30 days 30 days
Preventive Medications Limited to Listed Medications
Tier 1 $10 copay* 50% after deductible $10 copay* 50% after deductible
Tier 2 $35 copay* 50% after deductible $35 copay* 50% after deductible
Tier 3 $60 copay* 50% after deductible $60 copay* 50% after deductible
Tier 4 $60 copay* 50% after deductible $60 copay* 50% after deductible
Non-Preventive Medications
Tier 1 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Tier 2 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Tier 3 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Tier 4 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Mail Order—Supply 90 Days 90 Days
Limit
Tier 1 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Tier 2 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Tier 3 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Tier 4 70% after deductible 50% after deductible 80% after deductible 50% after deductible

* Mail order preventive drugs available in 90-day quantities and subject to 2 monthly copayments.
This is a high level summary of your benefit coverage. Full coverage details are available in your summary plan description (SPD). In
the event there is a discrepancy between what is reflected in this guide and what is communicated in your SPD, the terms of your
SPD will prevail.
Family Coverage — Embedded Deductibles and Out-of-Pocket

Maximums
Embedded deductibles means your plan has an individual deductible for each family member as well as
a maximum family deductible. When a family member meets his or her individual deductible, the plan
will begin sharing healthcare costs for this family member. The rest of the family still has to satisfy their
individual deductible. However, all individual expenses for each family member count toward the family
deductible. Once the family deductible is met (by more than one family member) the plan will share costs
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for all family members for the rest of the plan year. The same applies to the out-of-pocket maximum.