Comprehensive Health Plans (PPOs)

Self-Funded Plans (PPOs)

BENEFITS Premium Preferred Gold Bronze Level 1
Member Pays Member Pays Member Pays Member Pays Member Pays Member Pays Member Pays Member Pays
PLAN PROVISIONS Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*)
Annual Deductible $500 / Person
$1,500 / Family
$1,000 / Person
$3,000 / Family
$1,000 / Person
$3,000 / Family
$2,000 / Person
$6,000 / Family
$2,000 / Person
$6,000 / Family
$4,000 / Person
$12,000 / Family
$2,000 / Person
$6,000 / Family
$4,000 / Person
$12,000 / Family
Annual Out-of-Pocket
(Deductible, Copayment and Coinsurance)
$1,000 / Person
$3,000 / Family
$2,000 / Person
$6,000 / Family
$2,000 / Person
$6,000 / Family
$4,000 / Person
$12,000 / Family
$4,000 / Person
$12,000 / Family
$8,000 / Person
$24,000 / Family
$6,600 / Person
$13,200 / Family
$8,000 / Person
$24,000 / Family
Lifetime Maximum None None None None
MEDICAL SERVICES
PHYSICIAN SERVICES Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*)
Physician Office Visits
(including Specialist)
$10 Copayment per visit 30% Coinsurance after Annual Deductible $20 Copayment per visit 40% Coinsurance after Annual Deductible $25 Copayment per visit 50% Coinsurance after Annual Deductible $25 Copayment per visit 50% Coinsurance after Annual Deductible
Other Physician Services performed in the office or a Facility including Maternity 10% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible 15% Coinsurance after Annual Deductible 40% Coinsurance after Annual Deductible 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible
Urgent Care $20 Copayment per visit 30% Coinsurance after Annual Deductible $30 Copayment per visit 40% Coinsurance after Annual Deductible $35 Copayment per visit 50% Coinsurance after Annual Deductible $50 Copayment per visit 50% Coinsurance after Annual Deductible
Immunizations No Copayment 30% Coinsurance after Annual Deductible No Copayment 40% Coinsurance after Annual Deductible No Copayment 50% Coinsurance after Annual Deductible No Copayment 50% Coinsurance after Annual Deductible
PREVENTATIVE CARE Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*)
Well Child Care Office Visits - Immunizations - Lab Tests No Copayment 30% Coinsurance after Annual Deductible No Copayment 40% Coinsurance after Annual Deductible No Copayment 50% Coinsurance after Annual Deductible No Co-pay 50% Coinsurance after Annual Deductible
Physical Exam - Prostate Exam - Screenings - Counseling No Copayment 30% Coinsurance after Annual Deductible No Copayment 40% Coinsurance after Annual Deductible No Copayment 50% Coinsurance after Annual Deductible No Co-pay 50% Coinsurance after Annual Deductible
Well Women Exams - Pap Smears - Mammography No Copayment 30% Coinsurance after Annual Deductible No Copayment 40% Coinsurance after Annual Deductible No Copayment 50% Coinsurance after Annual Deductible No Co-pay 50% Coinsurance after Annual Deductible
HOSPITAL / FACILITY SERVICES Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*)
Inpatient Room & Care
(Semi-private room rate)  **
$100 Copayment per Day up to 3 Days plus amounts that exceed the Reasonable and Allowed Charge $150 Copayment per Day up to 3 Days plus amounts that exceed the Reasonable and Allowed Charge $200 Copayment per Day up to 3 Days plus amounts that exceed the Reasonable and Allowed Charge 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge *
Outpatient / Ambulatory Surgery Services & Birthing Centers   ** $100 Copayment plus amounts that exceed the Reasonable and Allowed Charge (waived if admitted to Inpatient status) $150 Copayment plus amounts that exceed the Reasonable and Allowed Charge (waived if admitted to Inpatient status) $200 Copayment plus amounts that exceed the Reasonable and Allowed Charge (waived if admitted to Inpatient status) $400 Copayment plus amounts that exceed the Reasonable and Allowed Charge *
Other Outpatient Hospital Services   ** - If at a hospital
(such as Cardiac, Pulmonary, PT/OT/ST)
10% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge 15% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge 20% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge *
Emergency Room Services $100 Copayment plus amounts that exceed the Reasonable and Allowed Charge (waived if admitted to Inpatient status) $150 Copayment plus amounts that exceed the Reasonable and Allowed Charge (waived if admitted to Inpatient status) $200 Copayment plus amounts that exceed the Reasonable and Allowed Charge (waived if admitted to Inpatient status) $500 Copayment plus amounts that exceed the Reasonable and Allowed Charge (waived if admitted to Inpatient status) *
DIAGNOSTIC SERVICES Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*)
Laboratory - Radiology - Scans (CT/MRI/PET)
Non Hospital Based No Copayment 30% Coinsurance after Annual Deductible No Copayment 40% Coinsurance after Annual Deductible No Copayment 50% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible
Hospital Based   ** 10% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge 15% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge 20% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge
MENTAL HEALTH
BEHAVIORAL HEALTH
SUBSTANCE ABUSE DISORDER
Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*)
INPATIENT
Hospital & Facility Services;
semi-private room rate   **
$100 Copayment per Day up to 3 Days plus amounts that exceed the Reasonable and Allowed Charge $150 Copayment per Day up to 3 Days plus amounts that exceed the Reasonable and Allowed Charge $150 Copayment per Day up to 3 Days plus amounts that exceed the Reasonable and Allowed Charge 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge
Psychiatrist & Psychologist Services 10% Coinsurance after Annual Deductible 10% Coinsurance after Annual Deductible 15% Coinsurance after Annual Deductible 15% Coinsurance after Annual Deductible 20% Coinsurance after Annual Deductible 20% Coinsurance after Annual Deductible 20% Coinsurance after Annual Deductible 20% Coinsurance after Annual Deductible
OUTPATIENT
Psychiatrist & Psychologist Services $10 Copayment per visit 30% Coinsurance after Annual Deductible $20 Copayment per visit 40% Coinsurance after Annual Deductible $25 Copayment per visit 50% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible
Psychological Testing   ** 10% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible 15% Coinsurance after Annual Deductible 40% Coinsurance after Annual Deductible 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible
OTHER SERVICES Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*)
Ambulance & Air Ambulance
** - (Non-emergent)
$150 Copayment plus amounts that exceed the Reasonable and Allowed Charge $200 Copayment plus amounts that exceed the Reasonable and Allowed Charge $250 Copayment plus amounts that exceed the Reasonable and Allowed Charge 30% Ground / 50% Air Coinsurance after Annual Deductible
Chemotherapy   ** 10% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible 15% Coinsurance after Annual Deductible 40% Coinsurance after Annual Deductible 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible
Dialysis and Supplies   ** 10% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge 15% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge 20% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge
Home Health Services   **
(Maximum of 120 visits per year)
10% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible 15% Coinsurance after Annual Deductible 40% Coinsurance after Annual Deductible 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible
Hospice Services   ** $20 Copayment per visit 30% Coinsurance after Annual Deductible $30 Copayment per visit 40% Coinsurance after Annual Deductible $35 Copayment per visit 50% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible
Physical/Occupational/Speech Therapy   **
(Non Hospital Based)
10% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible $30 Copayment per visit 40% Coinsurance after Annual Deductible $35 Copayment per visit 50% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible
ALTERNATIVE CARE SERVICES Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*)
Acupuncture - Chiropractic Care
Naturopathy - Message Therapy
(Maximum of $400 per Calendar Year)
$20 Copayment per visit 30% Coinsurance after Annual Deductible $30 Copayment per visit 40% Coinsurance after Annual Deductible $35 Copayment per visit 50% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible
PHARMACY BENEFITS Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*)
Prescription Drugs
Pharmacy Retail
Up to a 31 day supply
Except prescribed contraceptive methods
Generic - $10 Copayment
Preferred Brand - $20 Copayment
Non-Preferred Brand - $35 Copayment
Generic - $20 Copayment
Preferred Brand - $30 Copayment
Non-Preferred Brand - $45 Copayment
Generic - $25 Copayment
Preferred Brand - $40 Copayment
Non-Preferred Brand - $55 Copayment
Generic - $25 co-pay
Preferred Brand - $50 co-pay
Non-Preferred Brand - $75 co-pay
Prescription Drugs
Pharmacy Retail
90 Day Supply
Generic - $30 Copayment
Preferred Brand - $60 Copayment
Non-Preferred Brand - $105 Copayment
Generic - $60 Copayment
Preferred Brand - $90 Copayment
Non-Preferred Brand - $130 Copayment
Generic - $75 Copayment
Preferred Brand - $120 Copayment
Non-Preferred Brand - $165 Copayment
Generic - $75 co-pay
Preferred Brand - $150 co-pay
Non-Preferred Brand - $225 co-pay
Prescription Drugs
Pharmacy Mail Order
90 Day Supply
Generic - $20 Copayment
Preferred Brand - $40 Copayment
Non-Preferred Brand - $70 Copayment
Generic - $40 Copayment
Preferred Brand - $60 Copayment
Non-Preferred Brand - $90 Copayment
Generic - $50 Copayment
Preferred Brand - $80 Copayment
Non-Preferred Brand - $110 Copayment
Generic - $50 co-pay
Preferred Brand - $100 co-pay
Non-Preferred Brand - $150 co-pay
VISION CARE SERVICES Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*) Participating Providers Non-Participating Providers (*)
Vision Exam, Lenses, Frames, Contact Lens, Fittings, Lasik Surgery in lieu of Glasses $250 per year per covered member $250 per year per covered member $250 per year per covered member $250 per year per covered member
Monthly Cost
Employee Only $360.00 $348.00 $335.00 $317.00
Employee + Spouse $680.00 $656.00 $635.00 $588.00
Employee + Child(ren) $620.00 $595.00 $573.00 $545.00
Employee + Family $1,210.00 $1,160.00 $1,110.00 $885.00
* - Coinsurance amount is based on an approved Reasonable and Allowed reimbursement level.
** - Services Require Prior Authorization / Precertification
*** - After Plan Deductible
This summary provides a condensed explanation of plan benefits. Certain limitations, restrictions and exclusions may apply. Please refer to the Plan Document for complete information on benefits. In the case of discrepancy between this summary and the language contained in the Plan Document, the latter will take precedence.

Contact Riverstone Capital, LLC.