Page 7 - Castlerock Corporate

MEDICAL AND PHARMACY COVERAGE

Medical Plan Base Gold Platinum
Provisions In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Company Contribution to
HSA (Individual / Family) $500 / $1,000 N/A N/A
Annual Deductible
(Individual / Family) $3,000/$6,000 $6,000/$12,000 $1,500/$3,000 $3,000/$6,000 $500/$1,000 $1,000/$2,000
Out of Pocket Maximum $5,000/$10,000 $12,000/$24,000 $5,000/$10,000 $10,000/$20,000 $4,000/$8,000 $8,000/$16,000
(Includes Deductible)
Preventive Care Covered 100% 50% Coinsurance Covered 100% 50% Coinsurance Covered 100% 50% Coinsurance

Amount You Pay (after deductible, if applicable)
Primary Care Provider
20% 50% $25 copay 50% $25 copay 50%
Office Visit
Specialist
Office Visit 20% 50% $50 copay 50% $50 copay 50%

Telemedicine 20% N/A $25 copay N/A $25 copay N/A

Inpatient Hospital Services 20% 50% 20% 50% 20% 50%

Outpatient Hospital 20% 50% 20% 50% 20% 50%
Services

Urgent Care 20% 50% $75 copay 50% $75 copay 50%

Emergency Room 20% $250 copay $250 copay

Retail Pharmacy
Amount You Pay (after deductible, if applicable)
(up to a 30-day supply)
Generic 20% 50% $10 copay 50% $10 copay 50%

Brand (preferred) 20% 50% $35 copay 50% $35 copay 50%

Brand (non-preferred) 20% 50% $60 copay 50% $60 copay 50%
Mail Order Pharmacy Amount You Pay (after deductible, if applicable)
(90-day supply)
Generic 20% N/A $25 copay N/A $25 copay N/A

Brand (preferred) 20% N/A $88 copay N/A $88 copay N/A

Brand (non-preferred) 20% N/A $150 copay N/A $150 copay N/A

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