Medical

Our medical plan provides you access to both in-network and out-of-network providers, but you will get better discounts and pay less money out of pocket by remaining in-network.

All covered services are subject to medical necessity as determined by the plan. All out-of-network services are subjected to Reasonable and Customary (R&C) limitations. This means you are responsible for all charges over this allowance.

Maximize Your Benefits!

Out-of-network providers set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.

What would be the cost of out-of-network vs. in-network? (Example)

Provider charges $10,000 for services. Insurance carrier allowed amount is $6,000.

Out-of-network providerIn-network provider
$500Deductible$250Deductible
30% x $5,500 = $1,650($5,500 = $6,000 allowed amount – $500 deductible)10% x $5,750 = $575($5,750 = $6,000 allowed amount – $250 deductible)
4000 (balance billed amount)($4,000 = $10,000 billed – $6,000 allowed amount)+ No balance billingProviders cannot bill in excess of the allowed amount
$6,150is your responsibility$825is your responsibility

Medical Coverage Plan Summary

Sample Vendor 1Sample Vendor 2Sample Vendor 3
In-NetworkOut-of-NetworkIn-NetworkOut-of-NetworkIn-NetworkOut-of-Network
Deductible
Individual$X$X$X$X$X$X
Family$X$X$X$X$X$X
Out-of-Pocket Maximum
Individual$XX*$XX*$XX*$XX*$XX*$XX*
Family$XX*$XX*$XX*$XX*$XX*$XX*
Lifetime MaximumUnlimitedUnlimitedUnlimited
Coinsurance / Copays
Preventive Care$X%*$X%*$X%*$X%*$X%*$X%*
Primary Care Physician$X%*$X%*$X%*$X%*$X%*$X%*
Specialist$X%*$X%*$X%*$X%*$X%*$X%*
Diagnostics X-Ray and Lab$X%*$X%*$X%*$X%*$X%*$X%*
Urgent Care$X%*$X%*$X%*$X%*$X%*$X%*
Emergency Room$X%*$X%*$X%*$X%*$X%*$X%*
Inpatient Hospital Care$X%*$X%*$X%*$X%*$X%*$X%*
Outpatient Surgery$X%*$X%*$X%*$X%*$X%*$X%*
Pharmacy
Retail RX$X$X$X$X$X$X
(up to XX-days supply)
Mail Order RX$X$X$X$X$X$X
(up to XX-days supply)