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2025 Benefits Summary |
||
|---|---|---|
| In‐Network Provider | Out‐of‐Network Provider | |
| - Hospital | ||
|
Calendar Year Deductible |
BlueCard PPO/Carelon Behavioral Health - $500 / person; $1,000 / family |
Not covered |
|
Inpatient (Room and Board and Ancillary Services) |
90% of contract rate after $100 copay |
Not covered* |
|
Outpatient Surgery |
90% of contract rate after $100 copay |
Not covered |
|
Emergency Room |
90% of contract rate after $100 copay; emergency room copay is waived if immediately confined |
Not covered* |
|
Coinsurance Out‐of‐Pocket Limit |
$2,750/person; $5,500/family Combined hospital and medical (including MHSA) |
Not covered |
| - Medical*** | ||
|
Calendar Year Deductible |
BlueCard PPO/Carelon Behavioral Health ‐ $500 / person; $1,000 / family (combined w/Hospital) |
$500/person; $1,000/family |
|
Office Visit |
No deductible; 100% of contract rate after $25 copay (including telehealth**) |
Medical: 60% of Plan's allowance |
|
Surgeon |
90% of contract rate |
60% of Plan's allowance |
|
X‐ray and Lab |
90% of contract rate |
60% of Plan's allowance |
|
Therapy (Occupational, Osteopathic, Physical, Speech, Vision) |
90% of contract rate |
60% of Plan's allowance |
|
Maternity Care ‐ Prenatal Visits |
No deductible; 100% of contract rate |
60% of Plan's allowance |
|
Maternity Care ‐ Delivery |
90% of contract rate |
60% of Plan's allowance |
|
Routine Physical Exam |
No deductible; 100% of contract rate |
60% of Plan's allowance |
|
Routine Child Exam |
No deductible; 100% of contract rate |
60% of Plan's allowance |
|
Routine Mammogram/Pap |
No deductible; 100% of contract rate |
60% of Plan's allowance |
|
Hearing Aids |
90% of contract rate up to a maximum payment of $1,500 per device; one device per ear per |
60% of Plan's allowance up to a maximum payment of $1,500 per device; one device per ear per |
|
Coinsurance Out‐of‐Pocket Limit |
$2,750 / person; $5,500 / family |
None |
| - Overall Out‐of‐Pocket Maximum | ||
|
Hospital/Medical/Rx Out-of‐Pocket Maximum (includes Deductibles, Copays, Coinsurance)^^ |
$9,200/person; $18,400/family |
None |
| - Mental Health and Substance Use Disorders | ||
|
Carelon Behavioral Health In‐Network Provider |
Out‐of‐Network Provider |
|
|
Hospital and Alternative Levels of Care** |
Covered under Hospital Benefit |
Not covered* |
|
Outpatient |
Covered under Medical Benefit |
Covered under Medical Benefit |
| - Dental | ||
|
Delta Dental PPO In‐Network Provider |
Delta Premier and Out-of‐ Network Provider |
|
|
Deductible |
$75/person; $200/family |
$75/person; $200/family |
|
Diagnostic and Preventive Benefits |
No deductible; 100% |
75% |
|
Basic Benefits |
75% |
75% |
|
Major Benefits |
50% |
50% |
|
Calendar Year Maximum^ |
$2,500 |
$2,500 |
| - Vision - Exam Plus Plan | ||
|
Vision Service Plan (VSP) In‐Network Provider |
Out‐of‐Network Provider^^^ |
|
|
Eye Exams |
100% after $10 copay; One Exam Per Calendar Year |
80% up to a maximum Payment of $50; One Exam Per Calendar Year |
|
Glasses |
20% discount |
No benefit |
|
Professional Services for Contact Lenses |
15% discount |
No benefit |
2025 Benefits Summary continued |
||
|---|---|---|
| CVS Caremark Participating Retail Pharmacy | CVS Caremark Home Delivery | |
| - Prescription Drugs (CVS Caremark) | ||
|
Calendar Year Deductible |
$75/person; $150/family |
$75/person; $150/family |
|
Supply |
Up to 30 day supply prescription or refill |
Up to 90 day supply prescription or refill |
|
Copay for Generic |
(Tier 1)- $10 or 10% |
(Tier 1) - $20 or 10% ; max copay is $50/ prescription |
|
Copay for Preferred Brand |
(Tier 2) - $25 or 25% |
(Tier 2) - $50 or 25% ; max copay is $125/ prescription |
|
Copay for Non‐Preferred Brand |
(Tier 3) - $40 or 40% |
(Tier 3) - $100 or 40%; max copay is $300/prescription |
|
In addition, if you receive a brand name drug when a generic exists, you will pay the difference in cost between the generic and brand name medication. Generic preventive services medications, including contraceptives, are covered at 100% with no deductible or copay. |
In addition to the maximum copays listed above, if you receive a brand name drug when a generic exists, you will pay the difference in cost between the generic and brand name medication. Generic preventive services medications, including contraceptives, are covered at 100% with no deductible or copay. |
|
* The Affordable Care Act (ACA) defines certain care as essential benefits that must fall under health insurance covered. All other benefits and certain specialty medications are defined as non-essential.
**Alternative levels of care include Residential Treatment Center, Partial Hospital Program and Intensive Outpatient Program.
***Emergency treatment within 72 hours after an accident or within 24 hours of a sudden and serious illness will be covered at the In-Network Level of Benefits.
****RX Savings Solutions is an online service through which you and your enrolled dependents can find prescription medications at a lower cost. Register at myrxss.com.
^There is no dental maximum for individuals under age 19.
^^^Contact VSP at 800-877-7195 or www.vsp.com for Out-of-Network Provider allowances.
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