Page 13 - Trident 2022 Flipbook
P. 13
MEDICAL COVERAGE PLAN D
Plan D: PPO Plan
Plan Provision
In-Network Out-of-Network
Company Contribution to HSA N/A
Annual Deductible
Individual $300 $600
Family $600 $1,200
Out-of-Pocket Maximum (Excludes Deductible)
Individual $1,500 $3,000
Family $3,000 $6,000
Lifetime Maximum Unlimited
Preventive Care 100% Not Covered
Primary Physician Office Visit 100% after $15 Copay 60% after Deductible
Specialist Office Visit 100% after $15 copay 60% after Deductible
X-Ray and Lab 80% after Deductible 60% after Deductible
Inpatient Hospital Services 80% after Deductible 60% after Deductible
Outpatient Hospital Services 80% after Deductible 60% after Deductible
Urgent Care 100% after $15 copay 60% after Deductible
Emergency Room Care 100% after $100 Copay
The above is a summary of this benefit option.
Click here for more detailed information on this available benefit option.
2022 Trident Benefit Guide Page 13
