Core High Deductible Health Plan

Benefits

Basic Definition

Lower payroll deduction, higher deductible; generally, out-of-pocket expenses are higher

Calendar Year Deductible

In Network/Out of Network
Associate-only coverage: $2,000; Individual on Associate + Spouse, Child(ren) or Family coverage: $2,800 (family maximum: $6,000)

For Associate Plus (+) coverages, no benefits, except preventive care and certain preventive medications, are paid by the plan for any family member until that individual family member meets the $2,800 individual deductible amount or the total medical expenses paid by the family equal the $6,000 family deductible maximum amount.

Calendar Year Out-of-Pocket Maximum
(This is the amount you would pay before benefits would pay at 100%.)

In Network/Out of Network
Combined medical and prescription drugs: $6,900 individual; $13,800 family (includes $2,000 individual; $6,000 family medical deductible)

In Network
Deductibles, copays and coinsurance apply to the out-of- pocket maximum.

Out of Network 
Coinsurance applies to the out-of-pocket maximum.

Pre-certification is required for many services, including but not limited to hospital admissions, PET scans, CT scans, MRIs, MRAs, physician-administered drugs, inpatient rehab, home health care, etc. Generally, if pre-certification is not obtained, no benefits are available. See Contact Your Benefits Providers page for contact numbers.

Preventive Care

(See the Preventive Services Listing for details.)

In Network
100% coverage for all listed services

Out of Network
Not covered

Office Visit

In Network
75% coverage after calendar year deductible

Out of Network
55% Maximum Allowable Charge (MAC) coverage after calendar year deductible

Hospital Visit

In Network
75% coverage subject to the calendar year deductible and a separate $500 deductible per admission

Out of Network
55% MAC coverage subject to the calendar year deductible and a separate $500 deductible per admission

Emergency Services

In Network
75% coverage after calendar year deductible

Out of Network
75% MAC coverage after calendar year deductible

Chiropractic Care

In Network
75% coverage after calendar year deductible limit of 30 total visits per person per calendar year

Out of Network
75% coverage after calendar year deductible limit of 30 total visits per person per calendar year

Speech, Physical and Occupational (Hand) Therapy

In Network
75% coverage subject to calendar year deductible; limit of 40 habilitative and 40 rehabilitative visits per person per calendar year. Medical necessity review required for visits 20-40

Out of Network
75% coverage subject to calendar year deductible; limit of 40 habilitative and 40 rehabilitative visits per person per calendar year. Medical necessity review required for visits 20-40

PET Scans, CT Scans, MRIs and MRAs

In Network
Covered at 75%* of the allowance subject to the calendar year deductible

Out of Network
Covered at 55%* of the allowance subject to the calendar year deductible

*Pre-certification is required for these screenings. No coverage for noncertified procedures.