Page 6 - Think Goodness Enrollment Guide

MEDICAL AND PHARMACY COVERAGE

HDHP Local Plus/OAP PPO $1,500 LocalPlus/OAP
Medical Plan Provisions In-Network Out-of-Network In-Network Out-of-Network
Annual Deductible
(Individual/Family) $2,800/$5,600 $5,600/$11,200 $1,500/$3,000 $3,000/$6,000
Out-of-Pocket Maximum
(Includes Deductible) $5,000/$10,000 $10,000/$20,000 $5,000/$10,000 $10,000/$20,000
Preventive Care Covered at 100% Not covered Covered at 100% Not covered
Primary Care Provider Office Visit 10%* 40%* $30 50%*
Specialist Office Visit 10%* 40%* $60 50%*
Telemedicine 10%* Not covered $30 Not covered
X-Ray and Lab 10%* 40%* 20%* 50%*
Inpatient Hospital Services 10%* 40%* 20%* 50%*
Outpatient Hospital Services 10%* 40%* 20%* 50%*
Urgent Care 10%* 40%* $75 50%*
Emergency Room 10%* $250
Retail Pharmacy (up to a 30-day supply)
Generic $10* Not covered $10 Not covered
Brand Preferred $35* Not covered $35 Not covered
Brand Non-Preferred $60* Not covered $60 Not covered
Specialty $120* Not covered $120 Not covered
Mail Order Pharmacy (90-day supply)
Generic $25* Not covered $25 Not covered
Brand Preferred $88* Not covered $88 Not covered
Brand Non-Preferred $150* Not covered $150 Not covered
Specialty Not covered Not covered Not covered Not covered
*After deductible

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