Page 9 - Trident 2022 Flipbook

MEDICAL COVERAGE PLAN B

Plan B HDHP with HSA
Plan Provision
In-Network Out-of-Network
If you enroll in our Medical Plan B, the Rangers will contribute
Company Contribution to HSA $250 annually into your Health Savings Account (H.S.A.); over 24
pay periods.
Annual Deductible
Individual $4,500 $9,000
Family $9,000 $18,000
Out-of-Pocket Maximum
Individual $6,350 $12,700
Family $12,700 $25,400

Lifetime Maximum Unlimited

Preventive Care 100% Not covered

Primary Physician Office Visit 70% after Deductible 50% after Deductible

Specialist Office Visit 70% after Deductible 50% after Deductible

X-Ray and Lab 70% after Deductible 50% after Deductible

Inpatient Hospital Services 70% after Deductible 50% after Deductible

Outpatient Hospital Services 70% after Deductible 50% after Deductible

Urgent Care 70% after Deductible 50% after Deductible

Emergency Room Care 70% 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 9