MEDICAL BENEFITS – PLAN HIGHLIGHTS
PCY = Per Calendar Year ( January 1-December 31 )
Annual Deductible ( Individual / Family )
HRA Reimbursement ( Individual / Family of 2 / Family of 3 +)
Medical Plan
Preferred Participating Out-of-Network 1
$ 2,000 / $ 4,000 $ 2,000 / $ 4,000 $ 2,000 / N / A
$ 1,700 / $ 3,400 / $ 5,100
What You Pay 30 % 30 % 50 % Annual Out-of-Pocket Maximum
2 $ 5 , 000 / $ 10 , 000 $ 5 , 000 / $ 10 , 000 N / A
( Individual / Family ) Preventive Care No charge ( deductible waived ) No charge ( deductible waived ) 50 % ( deductible waived )
Outpatient Services
Office Visit
Telehealth
$ 30 copay per visit ( deductible waived )
$ 30 copay per visit ( deductible waived )
$ 30 copay + 50 % ( deductible waived )
Covered services are subject to a $ 0 copay . ( deductible is waived ) ( Services must be provided by MDLive to be eligible for coverage ; Medical services are covered ; Behavioral health services are not covered ; Telederm services are not covered )
Diagnostic Lab & X-Ray No Charge ( deductible waived ) No Charge ( deductible waived ) 50 % ( deductible waived ) Surgery 30 % after deductible 30 % after deductible 50 % after deductible Rehabilitation 30 % after deductible 30 % after deductible 50 % after deductible
Other Services
Chiropractic Care
Massage Therapy
Acupuncture
Urgent Care
Emergency Room ( copay waived if admitted )
$ 30 copay per visit ( deductible waived )
$ 30 copay per visit ( deductible waived )
$ 30 copay per visit ( deductible waived )
$ 30 copay per visit ( deductible waived )
$ 100 copay + 30 % after deductible
$ 30 copay per visit ( deductible waived )
Limited to 24-visit calendar year maximum
$ 30 copay per visit ( deductible waived )
Limited to 12-visit calendar year maximum
$ 30 copay per visit ( deductible waived )
Limited to 12-visit calendar year maximum
$ 30 copay per visit ( deductible waived )
$ 100 copay + 30 % after deductible
50 % ( deductible waived )
$ 30 copay + 50 % ( deductible waived )
$ 30 copay + 50 % ( deductible waived )
$ 30 copay per visit ( deductible waived )
$ 100 copay + 30 % after deductible ( Out of network is subject to the PPO / PAR deductible and out of pocket maximum )
Inpatient Hospitalization 30 % after deductible 30 % after deductible 50 % after deductible
1 . In-Network and Out-of-Network deductibles and Out of Pocket Maximums are separate . In-Network services will not credit to Out-of-Network services , and vice versa .
2 . Until the family Out-of-Pocket Maximum is reached , each person enrolled in the plan has an individual Out-of-Pocket Maximum of $ 5,000 . Even if you are enrolled as a family , you will still only need to meet that individual maximum before the plan pays 100 % of covered services In-Network .
Limitations : This benefit outline is for illustrative purposes only . Actual claims paid are subject to maximum allowable charge , frequencies , age limitations , terms and conditions of the contract .
IMPORTANT ! This medical plan sometimes requires prior authorization to receive coverage for certain planned services . If prior authorization is not obtained for a required service , you could be subject to additional cost shares not outlined here or denial of coverage . Please contact Innovative Care Management for prior authorization on ( 800 ) 441-6337 .
Prepared by Gallagher for the Employees of The Suquamish Tribe 6