Page 7 - Trident 2022 Flipbook

MEDICAL COVERAGE PLAN A

Plan A HDHP with HSA

Plan Provision In-Network Out-of-Network

If you enroll in our Medical Plan A, the Rangers will contribute $250 annually
Company Contribution to HSA
into your Health Savings Account (H.S.A.); over 24 pay periods.
Annual Deductible
1
Individual $1,400 Combined with In-Network
Family $2,800 Combined with In-Network
Out-of-Pocket Maximum (Includes Deductible)
Individual $1,500 $3,600
Family $3,000 $6,000

Lifetime Maximum Unlimited

Preventive Care 100% 60% after Deductible

Primary Physician Office Visit 80% after Deductible 60% after Deductible

Specialist Office Visit 80% after Deductible 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 80% after Deductible 60% after Deductible

Emergency Room Care 80% after Deductible

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 7