Beneflex Private Exchange EPO’s

BENEFITSEPO $20EPO $40
Member PaysMember Pays
PLAN PROVISIONSParticipating Providers
(PHCS)
Participating Providers
(PHCS)
Annual DeductibleNoneNone
Lifetime MaximumNoneNone
PHYSICIAN SERVICESParticipating Providers
(PHCS)
Participating Providers
(PHCS)
Physician Office Visits
(including Specialist)
$20 Co-pay$40 Co-pay
Other Physician Services performed in the office or a Facility including Maternity$20 Co-pay$40 Co-pay
Urgent Care$20 Co-pay$40 Co-pay
ImmunizationsNo Co-payNo Co-pay
PREVENTATIVE CAREParticipating Providers
(PHCS)
Participating Providers
(PHCS)
Well Child Care Office Visits - Immunizations - Lab TestsNo Co-payNo Co-pay
Physical Exam - Prostate Exam - Screenings - CounselingNo Co-payNo Co-pay
Well Women Exams - Pap Smears - MammographyNo Co-payNo Co-pay
HOSPITAL / FACILITY SERVICESParticipating Providers
(PHCS)
Participating Providers
(PHCS)
Inpatient Room & CareNo co-pay
(Reference Based Pricing)
$500 co-pay
(Reference Based Pricing)
Outpatient / Ambulatory Surgery Services & Birthing Centers **$20 co-pay
(Reference Based Pricing)
$250 co-pay
(Reference Based Pricing)
Other Outpatient Hospital Services ** - If at a hospital
(such as Cardiac, Pulmonary, PT/OT/ST)
$20 co-pay
(Reference Based Pricing)
$50 co-pay
(Reference Based Pricing)
Emergency Room Services$100 co-pay
(Reference Based Pricing)
$100 co-pay
(Reference Based Pricing)
DIAGNOSTIC SERVICESParticipating Providers
(PHCS)
Participating Providers
(PHCS)
Laboratory - Radiology - Scans (CT/MRI/PET)
Non Hospital BasedNo co-pay$50 co-pay
Hospital Based **No co-pay
(Reference Based Pricing)
$50 co-pay
(Reference Based Pricing)
MENTAL HEALTH
BEHAVIORAL HEALTH
SUBSTANCE ABUSE DISORDER
Participating Providers
(PHCS)
Participating Providers
(PHCS)
INPATIENT
Hospital & Facility Services;
semi-private room rate **
No co-pay
(Reference Based Pricing)
$500 co-pay
(Reference Based Pricing)
Psychiatrist & Psychologist ServicesNo co-pay$500 co-pay
OUTPATIENT
Psychiatrist & Psychologist Services$20 co-pay$40 co-pay
Psychological Testing **$20 co-pay$40 co-pay
OTHER SERVICESParticipating Providers
(PHCS)
Participating Providers
(PHCS)
Ambulance & Air Ambulance
** - (Non-emergent)
$50 co-pay
(Reference Based Pricing)
$150 co-pay
(Reference Based Pricing)
Chemotherapy **$20 co-pay
(Reference Based Pricing)
$250 co-pay
(Reference Based Pricing)
Dialysis and Supplies **No co-pay
(Reference Based Pricing)
Home Health Services **
(Maximum of 120 visits per year)
$20 co-pay$40 co-pay
Hospice Services **$20 co-pay
(Reference Based Pricing)
Physical/Occupational/Speech Therapy **
(Non Hospital Based)
$20 co-pay$40 co-pay
ALTERNATIVE CARE SERVICESParticipating Providers
(PHCS)
Participating Providers
(PHCS)
Acupuncture - Chiropractic Care
Naturopathy - Message Therapy
(Maximum of $400 per Calendar Year)
$20 co-pay$40 co-pay
PHARMACY BENEFITSParticipating Providers
(PHCS)
Participating Providers
(PHCS)
Prescription Drugs
Pharmacy Retail
Up to a 31 day supply
Except prescribed contraceptive methods
Generic - $10 co-pay
Preferred Brand - $25 co-pay
Non-Preferred Brand - $25 co-pay
Generic - $15 co-pay
Preferred Brand - $35 co-pay
Non-Preferred Brand - $35 co-pay
Prescription Drugs
Pharmacy Retail
90 Day Supply
Generic - $30 co-pay
Preferred Brand - $75 co-pay
Non-Preferred Brand - $75 co-pay
Generic - $45 co-pay
Preferred Brand - $105 co-pay
Non-Preferred Brand - $105 co-pay
Prescription Drugs
Pharmacy Mail Order
90 Day Supply
Generic - $20 co-pay
Preferred Brand - $50 co-pay
Non-Preferred Brand - $50 co-pay
VISION CARE SERVICESParticipating Providers
(PHCS)
Vision Exam, Lenses, Frames, Contact Lens, Fittings, Lasik Surgery in lieu of Glasses$250 per year per covered member$250 per year per covered member
Monthly Cost
Employee Only$379.00$345.00
Employee + Spouse$725.00$645.00
Employee + Child(ren)$675.00$593.00
Employee + Family$1,375.00$1,140.00
BENEFITSEPO $20EPO $40
Member PaysMember Pays
PLAN PROVISIONSParticipating Providers
(PHCS)
Participating Providers
(PHCS)
Annual DeductibleNoneNone
Annual Out-of-Pocket
(Deductible, Copayment and Coinsurance)
$1,500 / Person
$3,000 / Family
$3,000 / Person
$6,000 / Family
Lifetime MaximumNoneNone
MEDICAL SERVICES
PHYSICIAN SERVICESParticipating Providers
(PHCS)
Participating Providers
(PHCS)
Physician Office Visits
(including Specialist)
$20 Co-pay$40 Co-pay
Other Physician Services performed in the office or a Facility including Maternity$20 Co-pay$40 Co-pay
Urgent Care$20 Co-pay$40 Co-pay
ImmunizationsNo Co-payNo Co-pay
PREVENTATIVE CAREParticipating Providers
(PHCS)
Participating Providers
(PHCS)
Well Child Care Office Visits - Immunizations - Lab TestsNo Co-payNo Co-pay
Physical Exam - Prostate Exam - Screenings - CounselingNo Co-payNo Co-pay
Well Women Exams - Pap Smears - MammographyNo Co-payNo Co-pay
HOSPITAL / FACILITY SERVICESParticipating Providers
(PHCS)
Participating Providers
(PHCS)
Inpatient Room & CareNo co-pay
(Reference Based Pricing)
$500 co-pay
(Reference Based Pricing)
Outpatient / Ambulatory Surgery Services & Birthing Centers **$20 co-pay
(Reference Based Pricing)
$250 co-pay
(Reference Based Pricing)
Other Outpatient Hospital Services ** - If at a hospital
(such as Cardiac, Pulmonary, PT/OT/ST)
$20 co-pay
(Reference Based Pricing)
$50 co-pay
(Reference Based Pricing)
Emergency Room Services$100 co-pay
(Reference Based Pricing)
$100 co-pay
(Reference Based Pricing)
DIAGNOSTIC SERVICESParticipating Providers
(PHCS)
Participating Providers
(PHCS)
Laboratory - Radiology - Scans (CT/MRI/PET)
Non Hospital BasedNo co-pay$50 co-pay
Hospital Based **No co-pay
(Reference Based Pricing)
$50 co-pay
(Reference Based Pricing)
MENTAL HEALTH
BEHAVIORAL HEALTH
SUBSTANCE ABUSE DISORDER
Participating Providers
(PHCS)
Participating Providers
(PHCS)
INPATIENT
Hospital & Facility Services;
semi-private room rate **
No co-pay
(Reference Based Pricing)
$500 co-pay
(Reference Based Pricing)
Psychiatrist & Psychologist ServicesNo co-pay$500 co-pay
OUTPATIENT
Psychiatrist & Psychologist Services$20 co-pay$40 co-pay
Psychological Testing **$20 co-pay$40 co-pay
OTHER SERVICESParticipating Providers
(PHCS)
Participating Providers
(PHCS)
Ambulance & Air Ambulance
** - (Non-emergent)
$50 co-pay
(Reference Based Pricing)
$150 co-pay
(Reference Based Pricing)
Chemotherapy **$20 co-pay
(Reference Based Pricing)
$250 co-pay
(Reference Based Pricing)
Dialysis and Supplies **No co-pay
(Reference Based Pricing)
$40 co-pay
(Reference Based Pricing)
Home Health Services **
(Maximum of 120 visits per year)
$20 co-pay$40 co-pay
Hospice Services **$20 co-pay
(Reference Based Pricing)
$250 co-pay
(Reference Based Pricing)
Physical/Occupational/Speech Therapy **
(Non Hospital Based)
$20 co-pay$40 co-pay
ALTERNATIVE CARE SERVICESParticipating Providers
(PHCS)
Participating Providers
(PHCS)
Acupuncture - Chiropractic Care
Naturopathy - Message Therapy
(Maximum of $400 per Calendar Year)
$20 co-pay$40 co-pay
PHARMACY BENEFITSParticipating Providers
(PHCS)
Participating Providers
(PHCS)
Prescription Drugs
Pharmacy Retail
Up to a 31 day supply
Except prescribed contraceptive methods
Generic - $10 co-pay
Preferred Brand - $25 co-pay
Non-Preferred Brand - $25 co-pay
Generic - $15 co-pay
Preferred Brand - $35 co-pay
Non-Preferred Brand - $35 co-pay
Prescription Drugs
Pharmacy Retail
90 Day Supply
Generic - $30 co-pay
Preferred Brand - $75 co-pay
Non-Preferred Brand - $75 co-pay
Generic - $45 co-pay
Preferred Brand - $105 co-pay
Non-Preferred Brand - $105 co-pay
Prescription Drugs
Pharmacy Mail Order
90 Day Supply
Generic - $20 co-pay
Preferred Brand - $50 co-pay
Non-Preferred Brand - $50 co-pay
Generic - $30 co-pay
Preferred Brand - $70 co-pay
Non-Preferred Brand - $70 co-pay
VISION CARE SERVICESParticipating Providers
(PHCS)
Participating Providers
(PHCS)
Vision Exam, Lenses, Frames, Contact Lens, Fittings, Lasik Surgery in lieu of Glasses$250 per year per covered member$250 per year per covered member
Monthly Cost
Employee Only$379.00$345.00
Employee + Spouse$725.00$645.00
Employee + Child(ren)$675.00$593.00
Employee + Family$1,375.00$1,140.00
* - Coinsurance amount is based on an approved Reasonable and Allowedreimbursement level.
** - Services Require Prior Authorization / Precertification
*** - After Plan Deductible
This summary provides a condensed explanation of plan benefits. Certain limitations, restrictions and exclusions may apply. Please refer to the Plan Document for complete information on benefits. In the case of discrepancy between this summary and the language contained in the Plan Document, the latter will take precedence.

CALCULATE Monthly Plan Costs

* – Coinsurance amount is based on an approved Reasonable and Allowedreimbursement level.

** – Services Require Prior Authorization / Precertification

*** – After Plan Deductible

This summary provides a condensed explanation of plan benefits. Certain limitations, restrictions and exclusions may apply. Please refer to the Plan Document for complete information on benefits. In the case of discrepancy between this summary and the language contained in the Plan Document, the latter will take precedence. This information is intended to present only an outline and summary of benefits. We believe the rates and information herein to be accurate based on the information provided to us. Please note that the final rates, benefits, and group acceptability will all be determined at the time of enrollment by the underwriting carrier. Changes in enrollment, pre-existing conditions, and effective date of coverage may impact final rates. Rates may also vary depending on copays, deductibles, coinsurance, out-of- pocket maximums and other options requested. All plans are subject to underwriting and policy limitations and exclusions. Beneflex Insurance Services, LLC is not responsible for any errors represented on this website. We recommend that you review plan documentation for details as this analysis has been provided for illustrative and comparative purposes only. In the event of any discrepancies between the illustrated benefits and final benefits according to the Evidence of Coverage (EOC) booklet issued by the carrier, the EOC will be deemed accurate and will prevail. Do not cancel your current coverage until an application for coverage has been approved in writing, you have received your policy number from the carrier and have been instructed by Beneflex to proceed with written notification to cancel your current coverage.

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