Page 11 - Deweys Benefits Enrollments Guide

Medical & Prescription Drug

Core Plan
Group# 081767

Benefit Highlights Blue Options 1-2-3

In Network
Physician Services
Primary Care Physician Office Visit $35
Specialist Office Visit Deductible then 50%

Preventive Medical Services: Routine
preventive screenings, well-baby/child, and 0% (Plan covers 100%)
women's preventive care
Hospital/Emergency
Emergency Room Deductible then 50%

Urgent Care Deductible then 50%
Inpatient Hospitalization Services Deductible then 30%
Inpatient per Admission Copay $250
Outpatient Facility & Physician Charges Deductible then 50%
X-Rays and Lab work Deductible then 50%
High Technology Radiology (MRI, CAT, PET,
Deductible then 50%
etc.)
Prescription Drugs
Tier 1 $10
Tier 2 Member pays 100% to a maximum of $150*
Tier 3 Member pays 100% to a maximum of $150*
Tier 4 Members pays 100% to a maximum of $150*

Deductibles and Maximums Policy Year Deductible (5/1 through 4/30)
Individual Annual Deductible $5,000
Individual Annual Coinsurance Maximum $1,850
Individual Annual Out-of-Pocket Maximum $6,850
Family Annual Deductible $10,000
Family Annual Coinsurance Maximum $3,700
Family Annual Out-of-Pocket Maximum $13,700
*There is a $150 per Drug Maximum, for each 30-day supply of Tier 2-4 drugs.

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