Page 8 - 2022 Drive Open Enrollment Guide - Non Union

Medical and pharmacy coverage - KBA

Drive DeVilbiss Healthcare offers a choice of two additional medical plan options through Key Benefit Associates (KBA).
These plans are only offered to hourly warehouse and manufacturing employees.

Plan Name / Network MEC MEC Heavy
Network In-Network Benefits In-Network Benefits Out of Network Benefits

Deductible
Individual $0 $0 $500
Family $0 $0 $1,000
Coinsurance Plan Pays 100% Plan Pays 100% Plan Pays 40%
Out-of-Pocket Max
(Includes Ded, Copays &
Coinsurance)
Individual $0 $5,000 No Limit
Family $0 $13,200 No Limit
Preventive Care Services Covered 100% Covered 100% 40% after deductible
Office Visits (PCP / SCP) Not Covered Telemedicine Only Not covered
Lab, X-Ray & Diagnostics Not Covered $75 copay 40% after deductible

Outpatient Major Diagnostics Not Covered $500 copay 40% after deductible
(CT, PET, MRI, Nuclear Medicine)

Inpatient Hospital Not Covered Not covered Not covered
Outpatient Surgery (facility fee) Not Covered Not covered Not covered
Outpatient Surgery
(physician/surgeon) Not Covered Not covered Not covered
Urgent Care Services Not Covered Not covered Not covered
Emergency Room Not Covered Not covered Not covered
Outpatient Short Term Therapy & Not Covered Not covered Not covered
Rehabilitation Services
Virtual Visits/TeleHealth Benefits Unlimited Calls Unlimited Calls Not covered

Prescription Drugs
Rx Deductible Not Covered N/A N/A

Retail (Up to 31-day supply) Not Covered $15 Generics Only Not Covered

Mail Order (Up to 90-day supply) Not Covered Not covered Not Covered

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