Medical Benefits

Name: William Jewell
Address: United States

Open Access Plus	In-Network
Deductible (Individual/Family)	$2,500/$5,000
Coinsurance	80/20 In-Network 60/40 Out-of-Network
Out-of-Pocket Max (Individual/Family) (Includes Deductible & Coinsurance)	$4,500/$9,000 In-Network $9,000/$18,000 Out-of-Network
In-Network Office Visit	$40 PCP & Specialists In-Network 60/40 Out-of-Network
Telehealth Visit (Virtual Care)	$40 Copay
Routine Preventive Care (contract lists covered services)	100% In-Network Wellness Related Office Visit 100% 60/40 Out-of-Network
Inpatient Hospital	80/20 In-Network 60/40 Out-of-Network
Outpatient Hospital	80/20 In-Network 60/40 Out-of-Network
MRI, MRA,CT and PET scans performed in a Physicians Office, Imaging Center or Other Outpatient Setting (including a hospital)	80/20 In-Network 60/40 Out-of-Network
Emergency Room	$100 copay then deductible and coinsurance In-or Out-of-Network
Urgent Care	$50 copay (office visit and lab only) In-Network Deductible and Coinsurance Out-of-Network
Vision Exam (limited to 1 every calendar year)	$40 copay In-Network 60/40 Out-of-Network

Full-Time Employees 3/4 time and over	Under $45,000	At least $45,000 & under $70,000	At least $70,000 & over
Employee Only	$135.82	$158.46	$211.28
Employee + 1	$387.87	$462.45	$611.63
Family	$487.68	$636.11	$784.53

Downloads

LocalPlus	In-Network
Deductible (Individual/Family)	$1,500/$3,000
Coinsurance	100%
Out-of-Pocket Max (Individual/Family) (Includes Deductible & Coinsurance)	$1,500/$3,000
In-Network Office Visit	Covered at 100%
Telehealth Visit (Virtual Care)	Covered at 100%
Routine Preventive Care (contract lists covered services)	Covered at 100%
Inpatient Hospital	Deductible
Outpatient Hospital	Deductible
MRI, MRA,CT and PET scans performed in a Physicians Office, Imaging Center or Other Outpatient Setting (including a hospital)	Deductible
Emergency Room	Deductible
Urgent Care	Deductible
Vision Exam (limited to 1 every calendar year)	N/A