MEDICAL

Medical Coverage Options

Your health matters, and we’re committed to providing flexible options to meet your needs. All medical plans are offered through Medical Mutual, giving you access to a broad network of providers and comprehensive coverage. Below is an overview of the three plan choices available: PPO, Low HDHP, and High HDHP.

PPO Plan

The PPO plan offers predictable costs for routine care and prescriptions, making it a great choice for those who prefer copays over meeting a deductible for everyday services.

How It Works

Office Visits, Urgent Care & Prescriptions: Subject to a copay.
Other Services (e.g., inpatient/outpatient surgery, diagnostic testing): Subject to the deductible.
In-Network Savings: Claims are discounted based on the allowed amount, so you pay less when using in-network providers.

Why Choose PPO?

Lower out-of-pocket costs for routine care.
No need to meet a deductible for office visits and prescriptions.
Flexibility to see specialists without referrals.

High Deductible Health Plans (HDHP)

HDHPs are designed for those who want lower monthly premiums and the ability to pair their plan with a Health Savings Account (HSA) for tax-free savings.

How They Work

All Expenses (Medical & Prescriptions): Apply toward the deductible.
In-Network Savings: Claims are discounted based on the allowed amount.
After Deductible: All medical services are covered at 100%, and prescriptions switch to a simple copay.

Key Differences Between Low and High HDHP

Low HDHP: Lower deductible, higher premium.
High HDHP: Higher deductible, lower premium.

Why Choose HDHP?

Lower monthly premiums.
Opportunity to save pre-tax dollars in an HSA.
Full coverage after deductible is met.

PPO Plan Details

Benefits	In-Network	Out-of-Network
Annual Deductible (Individual/Family)	$800 / $1,600	$2,000 / $4,000
Deductible Embedded	Yes	Yes
Coinsurance	80%	60%
Out-of-Pocket Maximum (Individual/Family)	$5,000 / $10,000	Unlimited
Deductible Included in Out-of-Pocket Limits	Yes	Yes
Preventive Care	Covered in Full	60% after deductible
Office Visit / Exam	$25 Copay	60% after deductible
Outpatient Specialist Visit	$30 Copay	60% after deductible
Advanced Diagnostic Imaging	80% after deductible	60% after deductible
Inpatient Hospital Services	80% after deductible	60% after deductible
Outpatient Service	80% after deductible	60% after deductible
Emergency Services	$150 Copay	60% after deductible
Urgent Care Visits	$50 Copay	60% after deductible
Pharmacy Benefits
Retail Pharmacy
Tier 1 / Generic	$25 Copay	N/A
Tier 2 / Brand (Formulary/Preferred)	$75 Copay	N/A
Tier 3 / Brand (Non-Formulary/ Non-preferred)	$135 Copay	N/A
Mail Order Pharmacy
Tier 1 / Generic	$50 Copay	N/A
Tier 2 / Brand (Formulary/Preferred)	$150 Copay	N/A
Tier 3 / Brand (Non-Formulary/Non-preferred)	$270 Copay	N/A
Tier 4 / Specialty	20% to $150	N/A

HDHP Low Plan Details

Benefits	In-Network	Out-of-Network
Annual Deductible (Individual/Family)	$3,400 / $6,800	$6,000 / $12,000
Deductible Embedded	Yes	Yes
Coinsurance	100%	80%
Out-of-Pocket Maximum (Individual/Family)	$6,000 / $12,000	$12,000 / $24,000
Deductible Included in Out-of-Pocket Limits	Yes	Yes
Preventive Care	Covered in Full	80% after deductible
Office Visit / Exam	100% after deductible	80% after deductible
Outpatient Specialist Visit	100% after deductible	80% after deductible
Advanced Diagnostic Imaging	100% after deductible	80% after deductible
Inpatient Hospital Services	100% after deductible	80% after deductible
Outpatient Service	100% after deductible	80% after deductible
Emergency Services	100% after deductible	80% after deductible
Urgent Care Visits	100% after deductible	80% after deductible
Pharmacy Benefits
Retail Pharmacy
Tier 1 / Generic	Ded / $10 Copay	N/A
Tier 2 / Brand (Formulary/Preferred)	Ded / $30 Copay	N/A
Tier 3 / Brand (Non-Formulary/ Non-preferred)	Ded / $60 Copay	N/A
Mail Order Pharmacy
Tier 1 / Generic	Ded / $25 Copay	N/A
Tier 2 / Brand (Formulary/Preferred)	Ded / $75 Copay	N/A
Tier 3 / Brand (Non-Formulary/Non-preferred)	Ded / $150 Copay	N/A
Tier 4 / Specialty	Ded / $60 Copay	N/A

HDHP High Plan Details

Benefits	In-Network	Out-of-Network
Annual Deductible (Individual/Family)	$5,000 / $10,000	$10,000 / $20,000
Deductible Embedded	Yes	Yes
Coinsurance	100%	80%
Out-of-Pocket Maximum (Individual/Family)	$6,000 / $12,000	$12,000 / $24,000
Deductible Included in Out-of-Pocket Limits	Yes	Yes
Preventive Care	Covered in Full	80% after deductible
Office Visit / Exam	100% after deductible	80% after deductible
Outpatient Specialist Visit	100% after deductible	80% after deductible
Advanced Diagnostic Imaging	100% after deductible	80% after deductible
Inpatient Hospital Services	100% after deductible	80% after deductible
Outpatient Service	100% after deductible	80% after deductible
Emergency Services	100% after deductible	80% after deductible
Urgent Care Visits	100% after deductible	80% after deductible
Pharmacy Benefits
Retail Pharmacy
Tier 1 / Generic	Ded / $10 Copay	N/A
Tier 2 / Brand (Formulary/Preferred)	Ded / $30 Copay	N/A
Tier 3 / Brand (Non-Formulary/ Non-preferred)	Ded / $60 Copay	N/A
Mail Order Pharmacy
Tier 1 / Generic	Ded / $25 Copay	N/A
Tier 2 / Brand (Formulary/Preferred)	Ded / $75 Copay	N/A
Tier 3 / Brand (Non-Formulary/Non-preferred)	Ded / $150 Copay	N/A
Tier 4 / Specialty	Ded / $60 Copay	N/A