COVERAGE

_ HD Plan ln-Network Coverage HD Plan Out-of-Network Coverage CoPay Plan In-Network Coverage CoPay Plan Out-of-Network Coverage
Network HealthSmart - National N/A HealthSmart - National N/A
Plan Deductible Feature Deductible, then Plan pays 100% Deductible, then Plan pays 100% Copayments, then Plan pays 100% Copayments, then Plan pays 100%
Individual/Family Deductible $3,000/$9,000 $3,500/$9,500 $3,500/$10,SOO $4,000/$11,000
Individual/Family Maximum Out-of-Pocket $3,000/$9,000 $3,500/$9,500 $3,500/$10,500 $4,000/$11,000
Health Savings Account (HSA) Eligible Yes Yes No No
Required• Primary Care Provider (PCP) No No No No
Required • PCP Referral to Specialist No No No No
Prescription Drug Benefits Yes - Deductible, then Plan pays 100% Yes, Deductible, then Plan pays 100% Yes, copayments, then Plan pays 100% Yes, copayments, then Plan pays 100%

DOCTOR VISITS

_ HD Plan ln-Network Coverage HD Plan Out-of-Network Coverage CoPay Plan In-Network Coverage CoPay Plan Out-of-Network Coverage
Preventive Care Yes - $0 copay Yes - $0 copay Yes - $0 copay Yes - $0 copay
Virtual Health - Teladoc $30 per consultation $30 per consultation $0 per consultation SO per consultation
Primary Care Deductible, then Plan pays 100% Deductible, then Plan pays 100% $35 copay $40 copay
Specialist Deductible, then Plan pays 100% Deductible, then Plan pays 100% $35 copay $40 copay

Office Services

_ HD Plan ln-Network Coverage HD Plan Out-of-Network Coverage CoPay Plan In-Network Coverage CoPay Plan Out-of-Network Coverage
Allergy Injections Deductible, then Plan pays 100% Deductible, then Plan pays 100% $5 copay $10 copay
Allergy Serum Deductible, then Plan pays 100% Deductible, then Plan pays 100% $35 copay $40 copay
Chiropractic Services Deductible, then Plan pays 100% Deductible, then Plan pays 100% $35 copay $40 copay
Office Surgery Deductible, then Plan pays 100% Deductible, then Plan pays 100% $110 copay $125 copay
MRl's, Cat Scans, and Pet Scans Deductible, then Plan pays 100% Deductible, then Plan pays 100% $275 copay $325 copay
Urgent Care Facility Deductible, then Plan pays 100% Deductible, then Plan pays 100% $50 copay $75 copay

Care Facilities

_ HD Plan ln-Network Coverage HD Plan Out-of-Network Coverage CoPay Plan In-Network Coverage CoPay Plan Out-of-Network Coverage
Urgent Care Facility Deductible, then Plan pays 100% Deductible, then Plan pays 100% $50 copay $75 copay
Freestanding Emergency Room Deductible, then Plan pays 100% Deductible, then Plan pays 100% $500 copay $500 copay
Hospital Emergency Room Deductible, then Plan pays 100% Deductible, then Plan pays 100% $500 copay $500 copay
Ambulance Services Deductible, then Plan pays 100% Deductible, then Plan pays 100% $220 copay $220 copay
Outpatient Surgery Deductible, then Plan pays 100% In-Network Only $500 copay In-Network Only
Hospital Services Deductible, then Plan pays 100% In-Network Only $500 copay In-Network Only
Surgeon Fees Deductible, then Plan pays 100% In-Network Only $100 copay In-Network Only

Maternity and Newborn Services

_ HD Plan ln-Network Coverage HD Plan Out-of-Network Coverage CoPay Plan In-Network Coverage CoPay Plan Out-of-Network Coverage
Maternity Charges (prenatal and postnatal care) Deductible, then Plan pays 100% In-Network Only $500 copay In-Network Only
Routine Newborn Care Deductible, then Plan pays 100% In-Network Only $250 copay In-Network Only

Rehabilitation/Therapy

_ HD Plan ln-Network Coverage HD Plan Out-of-Network Coverage CoPay Plan In-Network Coverage CoPay Plan Out-of-Network Coverage
Occupational/Speech/Physical Deductible, then Plan pays 100% Deductible, then Plan pays 100%* $55 copay $65 copay*
Cardiac Rehabilitation Deductible, then Plan pays 100% Deductible, then Plan pays 100%* $110 copay $125 copay*
Chemotherapy, Radiation, Dialysis Deductible, then Plan pays 100% Deductible, then Plan pays 100%* $110 copay $125 copay*
Home Health Care Deductible, then Plan pays 100% Deductible, then Plan pays 100%* $55 copay $75 copay*
Skilled Nursing Deductible, then Plan pays 100% In-Network Only $500 copay In-Network Only

Care Coordinator*

  • The Care Coordinator program must be used to access facility services or no benefits will be available under the Plan.

    These services include routine colonoscopy and related services; hospital providers for MRls, Cat Scans, and Pet Scans; hospital providers for outpatient Lab/Radiology Services; Inpatient Hospital Admissions; Outpatient Hospital/Ambulatory Surgical Facility Services; Maternity and Newborn Services; Rehabilitation/Therapy Services; Extended Care Services; and Other Services Including durable medical equipment/supplies, orthotics/prosthetics, facilities for diabetic self-management training, and sleep disorder services. To review the complete plan document and services that require access through the Care Coordinator program, please call 888-803-0081.