Plan Comparison

This is an easy-to-read benefit summary comparison and does not include all benefits. If there is a conflict between this summary and your plan documents, your plan documents are correct. For more details about your benefits or to find out which treatments/services require prior authorization, please refer to your Summary Plan Description (SPD).

Medical Benefits - In Network - What you pay (unless otherwise noted)
Calendar Year Deductible (Medical)
Annual Out-of-Pocket Spending Limits (Network Medical & Prescription Drug)
Most Out-of-Network Services
Office Visits & Laboratory Services
Preventive Care
Primary Care
Specialist
Mental Health/Substance Abuse
Laboratory Services
Urgent Care, Hospital Services, Surgery
Urgent Care Center
Emergency Room (ER)
Outpatient Surgery
Inpatient Hospitalization
Imaging
Radiology (X-ray)
Diagnostic Imaging (CT, MRI, PET)
Prescription Drug
Daily Supply Limit
Certain Preventive Drugs
Most Generic Drugs
Most Brand Drugs
Specialty Drugs