Page 9 - Burke Hospital 2022 Benefits Summary
P. 9
Brief Summary of Medical Plan Benefits
EPO Core
(In-Network Only)
EPO High
(In-Network Only)
Office Visit Copay: (PCP/Specialist)
$30/$50
$25/$40
Deductible: (Individual/Family)
$1,500/$3,000
N/A
Coinsurance %
80%
N/A
Out-of-Pocket Maximum
$4,500/$9,000
$5,500/$11,000
Inpatient Services
Emergency Room Copay
$250
$150
Hospital Admission
Deductible & Coinsurance
$250
Outpatient Services
Hospital Outpatient Copay
$400
$100
Pharmacy Copays (Retail Store)
$15 (Tier 1) Deductble, then $30 (Tier 2) Deductuble, then $75 (Tier 3)
$15 (Tier 1) $30 (Tier 2) $50 (Tier 3)
Pharmacy Copays (Mail Order)
$37.50 (Tier 1) Deductible, then $75 (Tier 2) Deductible, then $187.50 (Tier 3)
$37.50 (Tier 1) $75 (Tier 2) $125 (Tier 3)
Please refer to full Summary of Benefits enclosure for fee schedule for more services.
2022 Benefits Summary Hospital 9
