Core Deductible Health Plan

benefits-chapter

Basic Definition	Lower payroll deduction, higher deductible and generally out-of-pocket expenses are higher.
Calendar Year Deductible	In Network / Out of Network Associate-only coverage: $2,000; Individual on Associate Plus Spouse, Child(ren) or Family Coverage: $2,700 Family maximum: $6,000 For Associate Plus coverages, no benefits, except preventive care, are paid by the plan to any family member until that individual family member meets the $2,700 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 paid at 100%.)	In Network / Out of Network Separate Medical: $3,375 individual; $10,125 family (Includes $2,000 individual; $6,000 family medical deductible). Separate Prescription Drugs: $3,375/individual or family. In-Network: Deductibles, Co-pays and Coinsurance apply to the out-of- pocket maximum. Out of Network: Coinsurance applies to the out-of-pocket maximum.
Preventive Care (See the Preventive Services Listing for details.)	In Network 100 percent coverage for all listed services Out of Network Not covered
Office Visit	In Network 75 percent coverage after calendar year deductible Out of Network 55 percent MAC coverage (MAC*) after calendar year deductible
Hospital Visit	In Network 75 percent coverage after $500 per-admission co-pay Out of Network 55 percent MAC coverage after $500 per-admission co-pay
Emergency Services	In Network 75 percent coverage after calendar year deductible Out of Network 75 percent MAC coverage after calendar year deductible
Chiropractic Care	In Network 75 percent coverage after calendar year deductible limit of 30 total visits per person per calendar year Out of Network 75 percent coverage after calendar year deductible limit of 30 total visits per person per calendar year
Speech, Physical and Occupational (hand) Therapy	In Network 75 percent 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 percent 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, MRI and MRA's	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