Page 6 - Benefit Guide

Medical and pharmacy coverage

Plan Name Plan Name Plan Name

Medical Plan Provisions In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Company contribution to $XXX/$XXXX $XXX/$XXXX $XXX/$XXXX
HRA/HSA (Individual/Family)
Annual Deductible $XXX/$XXXX $XXX/$XXXX $XXX/$XXXX $XXX/$XXXX $XXX/$XXXX $XXX/$XXXX
(Individual/Family)
Out-of-Pocket Maximum $XXX/$XXXX $XXX/$XXXX $XXX/$XXXX $XXX/$XXXX $XXX/$XXXX $XXX/$XXXX
(Includes Deductible)
Covered at XX% Covered at XX% Covered at XX%
Preventive Care 100% 100% 100%

Primary Care Provider Amount you pay after deductible
Office Visit
Specialist Office Visit XX% XX% XX% XX% XX% XX%
X-Ray and Lab
Inpatient Hospital Services XX% XX% XX% XX% XX% XX%
Outpatient Hospital Services XX% XX% XX% XX% XX% XX%
Urgent Care XX% XX% XX% XX% XX% XX%
Emergency Room XX% XX% XX% XX% XX% XX%
XX% XX% XX% XX% XX% XX%

XX% XX% XX%

Pharmacy Provisions In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Prescription Drug Deductible $XXX/$XXXX $XXX/$XXXX $XXX/$XXXX $XXX/$XXXX $XXX/$XXXX $XXX/$XXXX
(Individual/Family)

Retail pharmacy (up to a 30-day supply) Amount you pay after deductible

Generic XX% XX% XX% XX% XX% XX%

Brand Preferred XX% XX% XX% XX% XX% XX%

Brand Non-Preferred XX% XX% XX% XX% XX% XX%

Specialty XX% XX% XX% XX% XX% XX%

Mail Order Pharmacy (90-day supply) Amount you pay after deductible

Generic XX% XX% XX% XX% XX% XX%

Brand Preferred XX% XX% XX% XX% XX% XX%

Brand Non-Preferred XX% XX% XX% XX% XX% XX%

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