Plan Unit 376
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).
Platinum+ PPO
Gold+ PPO
Medical Benefits - In Network - What you pay (unless otherwise noted)
$0
$0
Medical: $5,000 individual/$10,000 family
Prescription Drug: $1,600 individual/$3,200 family
Medical: $5,000 individual/$10,000 family
Prescription Drug: $1,600 individual/$3,200 family
50%
50%
Office Visits & Laboratory Services
$0 (not covered out-of-network)
$0 (not covered out-of-network)
$10 copay
$20 copay
$20 copay
$40 copay
$10 copay
$20 copay
Office/Non-Hospital: $0 copay
Hospital: $30 copay
Office/Non-Hospital: $20 copay
Hospital: $80 copay
Urgent Care, Hospital Services, Surgery
$25 copay
$40 copay
$100 copay
Copay waived if admitted
(same benefits out-of-network)
$150 copay
Copay waived if admitted
(same benefits out-of-network)
Ambulatory Surgical Center: $25 copay
Hospital Outpatient: $75 copay
Ambulatory Surgical Center: $150 copay
Hospital Outpatient: $250 copay
$100 copay/day,
$200 max copay/admission
$250 copay/day,
$750 max copay/admission
Imaging
Non-Hospital: $0
Hospital: $30 copay
Non-Hospital: $20 copay
Hospital: $80 copay
Non-Hospital: $0
Hospital: $50 copay
Non-Hospital: $150 copay
Hospital: $250 copay
Prescription Drug
34-day retail; 60-day mail
34-day retail; 60-day mail
$0
$0
$3 copay
$5 copay
Preferred: $15 copay
Non-Preferred: $30 copay
Preferred: $15 copay
Non-Preferred: $30 copay
Generic: $3 copay
Brand: 25% coinsurance
(mail order only)
Generic: $5 copay
Brand: 25% coinsurance
(mail order only)
