Page 7 - NRDC Benefits Guide for 2022

Medical Plan Options at a Glance

Open Access Plus Plan Open Access Plus HDHP Plan
You Pay You Pay You Pay You Pay
In Network Out of Network In Network Out of Network
Deductible (Single / Family) None $500 / $1,000 $1,400 / $2,800 $2,800 / $5,600

Deductible Structure Embedded Non-Embedded
Out-of-Pocket Limit $2,500 / $5,000 $2,500 / $5,000 $2,500 / $5,000 $3,500 / $7,000
(Single / Family)
OOP Limit Structure Embedded Non-Embedded

co-insurance 100% 80% 90% 80%
Preventive Care Covered 100% Not Covered Covered 100% Not Covered

Primary Care / Specialist Visit $15 co-pay 20% After Ded. 10% After Ded. 20% After Ded.

Emergency Room $100 co-pay 10% After Ded.
Urgent Care $35 co-pay 20% After Ded. 10% After Ded. 20% After Ded.

Ambulance Service No Charge 10% After Ded.

X-Ray & Lab Covered 100% 20% After Ded. 10% After Ded. 20% After Ded.
Advanced Diagnostic Covered 100% 20% After Ded. 10% After Ded. 20% After Ded.

Inpatient Hospital $500 co-pay 20% After Ded. 10% After Ded. 20% After Ded.

Outpatient Surgery Covered 100% 20% After Ded. 10% After Ded. 20% After Ded.
$15 co-pay (12 days
Acupuncture (PCP or Specialist) 20% After Ded. 10% After Ded. 20% After Ded.
per calendar year)
Infertility & Advanced Treatments** $15 co-pay 20% After Ded. 10% After Ded. 20% After Ded.
Autism Coverage $15 co-pay 20% After Ded. 10% After Ded. 20% After Ded.

Retail Prescription Drugs - 30-day Supply**
$10 co-pay After
Tier 1 $10 co-pay Not Covered Not Covered
Ded.
$20 co-pay After
Tier 2 $20 co-pay Not Covered Not Covered
Ded.
$30 co-pay After
Tier 3 $30 co-pay Not Covered Not Covered
Ded.
Mail Order Prescription Drugs - 90-day supply
$25 co-pay After
Tier 1 $25 co-pay Not Covered Not Covered
Ded.
$50 co-pay After
Tier 2 $50 co-pay Not Covered Not Covered
Ded.
$75 co-pay After
Tier 3 $75 co-pay Not Covered Not Covered
Ded.
*$50k Lifetime Maximum for in-vitro fertilization, GIFT, ZIFT, etc.
** Certain medications that treat chronic conditions may be covered subject to co-pay only (not subject to deductible) under HDHP
plans.

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