Important Plan Documents

 

HMO Forms

Enrollment Form
Change Form
Prescription Mail Order Form
COBRA Enrollment Form

HMO High
Schedule of Benefits
Rx Highlights
Mental Health Benefits

HMO Low
Schedule of Benefits
Rx Highlights
Mental Health Benefits

PPO/HSA Forms

Enrollment Form

PPO
Schedule of Benefits
Prescription Coverage
Certificate of Coverage (Booklet)

HSA
Schedule of Benefits
Prescription Coverage
Certificate of Coverage (Booklet)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Benefits

There are 4 Medical plans to choose from - two HMOs a PPO, and an HSA. There is a side-by-side comparison of some basic features below. This is not an exhaustive list. Please refer to your Evidences of Coverage for complete information. To have an Evidence of Coverage sent to you, contact us.

 

 

 

Plan Summary

	HMO High	HMO Low	PPO (In-Network)	HSA (in-Network)
Calendar Year Deductible	None	None	$500 per Covered Person, $1,000 per Family	$2,500 per Covered Person, $5,000 per Family
Maximum Benefit	Unlimited	Unlimited	$5,000,000	$5,000,000
Office Visits	$15/30 Copayment	$30 Copayment	$20 Copayment	20% of Eligible Expenses (after deductible)
Emergency Services	$100 Copayment (waived if admitted)	$100 Copayment (waived if admitted)	$100 per visit	20% of Eligible Expenses (after deductible)
Hospital Services	$300 Copayment per admit	$500 Copayment per admit	10% of Eligible Expenses (after deductible)	20% of Eligible Expenses (after deductible)
Ambulance	Paid in Full	$50 Copayment	10% of Eligible Expenses (after deductible)	20% of Eligible Expenses (after deductible)
Durable Medical Equipment	Paid in Full	$50 Copayment	10% of Eligible Expenses (after deductible)	20% of Eligible Expenses (after deductible)
Home Health Care	$15 Copayment per visit	$10 Copayment per visit	10% of Eligible Expenses (after deductible)	20% of Eligible Expenses (after deductible)
Prescriptions	Retail: Brand - $30 Generic - $20 Non-Formulary - $50 Mail-Order: Brand - $60 Generic - $40 Non-Formulary - $100	Retail: Brand - $30 Generic - $20 Non-Formulary - $50 Mail-Order: Brand - $60 Generic - $40 Non-Formulary - $100	Tier 1: $10 retail/$25 mailorder Tier 2: $30 retail/$75 mailorder Tier 3: $50 retail/$125 mailorder	Tier 1: $10 retail/$25 mailorder Tier 2: $30 retail/$75 mailorder Tier 3: $50 retail/$125 mailorder
X-Ray & Laboratory	Paid in Full (unless specialized procedure, then $125Copayment)	Paid in Full (unless specialized procedure, then $50Copayment)	10% of Eligible Expenses (after deductible)	Paid in Full (unless specialized procedure, then 30% of Eligible Expenses)
Skilled Nursing Facility	$300 Copayment per admit	$200 Copayment per admit	10% of Eligible Expenses (after deductible)	20% of Eligible Expenses (after deductible)