Page 8 - Moonwell Studios Benefit Guide

Medical Plan Highlights

Blue Shield Blue Shield
Plan Name Silver HSA PPO Gold PPO
Network Name Full PPO Non-Network* Full PPO Non-Network*
Plan Differences

Employee Premiums $ $$$

Health Savings Account
- Moonwell Studios Funded ✓
- Employee Funded ✓

Employee Cost Sharing Contribution, Deductible, Copay, Contribution, Deductible, Copay,
Coinsurance Coinsurance
Network
- Network Size  
- In-Network Benefits ✓ ✓
- Non-Network Benefits ✓ ✓

Access to Providers Managed by You Managed by You
Health Benefits
Lifetime Maximum Benefit Unlimited Unlimited

Calendar Year Deductible
- Individual $2,000 $4,000 $500 $1,000
- Family (per member) $4,000 ($2,800) $8,000 ($4,000) $1,000 $2,000

Out-of-Pocket Maximum
- Individual $6,500 $12,550 $7,800 $13,850
- Family $7,500 $25,100 $15,600 $27,700
Coinsurance (You Pay) 25% 50% 20% 40%

Office Visit Copay
- Preventive Care No Charge Not Covered No Charge Not Covered
- Primary Care Physician Deductible, 25% Deductible, 50% $30 Copay Deductible, 40%
- Specialist Deductible, 25% Deductible, 50% $50 Copay Deductible, 40%
- Urgent Care Deductible, 25% Deductible, 50% $30 Copay Deductible, 40%
- Virtual Visit Deductible, $5 Copay Not Covered $5 Copay Not Covered

Hospitalization
- Inpatient Deductible, 25% Deductible, 50% Deductible, 20% Deductible, 40%
- Outpatient Surgery Deductible, $150 Deductible, 50% Deductible, $150 Deductible, 40%
Copay, 25% Copay, 20%

Lab and X-Ray
- Diagnostic Deductible, 25% Deductible, 50% $30 - $50 Copay Deductible, 40%
- Complex Deductible, 25% Deductible, 50% Deductible, $100 Deductible, 40%
Copay, 20%
Emergency Services Deductible, $150 Copay, 25% Deductible, $250 Copay, 20%
Chiropractic Deductible, 25% Deductible, 50% $10 Copay Deductible, 50%
Max 20 Visits/Year Max 20 Visits/Year
*Benefit limitations apply

8 Employee Benefits