Beneflex Private Exchange PPO’s

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BENEFITSPlatinum 500Gold 1000Silver 2000Bronze 5000Bronze 2000
Member PaysMember PaysMember PaysMember PaysMember PaysMember PaysMember PaysMember PaysMember Pays
PLAN PROVISIONSParticipating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating Providers
(PHCS)
Participating ProvidersNon-Participating Providers (*)
Annual Deductible$500 / Person
$1,500 / Family
$1,000 / Person
$3,000 / Family
$1,000 / Person
$3,000 / Family
$2,000 / Person
$6,000 / Family
$2,000 / Person
$6,000 / Family
$4,000 / Person
$12,000 / Family
$5,000 / Person
$10,000 / Family
$2,000 / Person
$6,000 / Family
$4,000 / Person
$12,000 / Family
$6,000 / Family$12,000 / Family
Annual Out-of-Pocket
(Deductible, Copayment and Coinsurance)
$1,000 / Person
$3,000 / Family
$2,000 / Person
$6,000 / Family
$2,000 / Person
$6,000 / Family
$4,000 / Person
$12,000 / Family
$4,000 / Person
$12,000 / Family
$8,000 / Person
$24,000 / Family
$6,250 / Person
$12,500 / Family
$6,600 / Person
$13,200 / Family
$8,000 / Person
$24,000 / Family
$13,200 / Family$24,000 / Family
Lifetime MaximumNoneNoneNoneNoneNone
MEDICAL SERVICES
PHYSICIAN SERVICESParticipating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating Providers
(PHCS)
Participating ProvidersNon-Participating Providers (*)
Physician Office Visits
(including Specialist)
$10 Copayment per visit30% Coinsurance after Annual Deductible$20 Copayment per visit40% Coinsurance after Annual Deductible$25 Copayment per visit50% Coinsurance after Annual Deductible$60 Co-pay ***$25 Copayment per visit50% Coinsurance after Annual Deductible
Other Physician Services performed in the office or a Facility including Maternity10% Coinsurance after Annual Deductible30% Coinsurance after Annual Deductible15% Coinsurance after Annual Deductible40% Coinsurance after Annual Deductible20% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible$60 Co-pay ***30% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible
Urgent Care$20 Copayment per visit30% Coinsurance after Annual Deductible$30 Copayment per visit40% Coinsurance after Annual Deductible$35 Copayment per visit50% Coinsurance after Annual Deductible$60 Co-pay ***$50 Copayment per visit50% Coinsurance after Annual Deductible
ImmunizationsNo Copayment30% Coinsurance after Annual DeductibleNo Copayment40% Coinsurance after Annual DeductibleNo Copayment50% Coinsurance after Annual DeductibleNo Co-payNo Copayment50% Coinsurance after Annual Deductible
PREVENTATIVE CAREParticipating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating Providers
(PHCS)
Participating ProvidersNon-Participating Providers (*)
Well Child Care Office Visits - Immunizations - Lab TestsNo Copayment30% Coinsurance after Annual DeductibleNo Copayment40% Coinsurance after Annual DeductibleNo Copayment50% Coinsurance after Annual DeductibleNo Co-payNo Co-pay50% Coinsurance after Annual Deductible
Physical Exam - Prostate Exam - Screenings - CounselingNo Copayment30% Coinsurance after Annual DeductibleNo Copayment40% Coinsurance after Annual DeductibleNo Copayment50% Coinsurance after Annual DeductibleNo Co-payNo Co-pay50% Coinsurance after Annual Deductible
Well Women Exams - Pap Smears - MammographyNo Copayment30% Coinsurance after Annual DeductibleNo Copayment40% Coinsurance after Annual DeductibleNo Copayment50% Coinsurance after Annual DeductibleNo Co-payNo Co-pay50% Coinsurance after Annual Deductible
HOSPITAL / FACILITY SERVICESParticipating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating Providers
(PHCS)
Participating ProvidersNon-Participating Providers (*)
Inpatient Room & Care
(Semi-private room rate) **
$100 copay, 10% after ded.$100 copay, 30% after ded.$100 copay, 15% after ded.$100 copay, 40% after ded.$100 copay, 20% after ded.$200 copay, 50% after ded.30% Coinsurance ***
(Reference Based Pricing)
40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge *
Outpatient / Ambulatory Surgery Services & Birthing Centers **$100 copay, 10% after ded.$100 copay, 30% after ded.$100 copay, 15% after ded.$100 copay, 40% after ded.$100 copay, 20% after ded.$200 copay, 50% after ded.30% Coinsurance ***
(Reference Based Pricing)
$400 Copayment plus amounts that exceed the Reasonable and Allowed Charge *
Other Outpatient Hospital Services ** - If at a hospital
(such as Cardiac, Pulmonary, PT/OT/ST)
$100 copay, 10% after ded.$100 copay, 30% after ded.$100 copay, 15% after ded.$100 copay, 40% after ded.$100 copay, 20% after ded.$200 copay, 50% after ded.30% Coinsurance ***
(Reference Based Pricing)
40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge *
Emergency Room Services$100 copay, 10% after ded.$100 copay, 30% after ded.$100 copay, 15% after ded.$100 copay, 40% after ded.$100 copay, 20% after ded.$200 copay, 50% after ded.$300 co-pay ***
(Reference Based Pricing)
$500 Copayment plus amounts that exceed the Reasonable and Allowed Charge (waived if admitted to Inpatient status) *
DIAGNOSTIC SERVICESParticipating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating Providers
(PHCS)
Participating ProvidersNon-Participating Providers (*)
Laboratory - Radiology - Scans (CT/MRI/PET)
Non Hospital BasedNo Copayment30% Coinsurance after Annual DeductibleNo Copayment40% Coinsurance after Annual DeductibleNo Copayment50% Coinsurance after Annual Deductible30% Coinsurance ***30% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible
Hospital Based **10% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge15% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge20% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge30% Coinsurance ***
(Reference Based Pricing)
40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge
MENTAL HEALTH
BEHAVIORAL HEALTH
SUBSTANCE ABUSE DISORDER
Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating Providers
(PHCS)
Participating ProvidersNon-Participating Providers (*)
INPATIENT
Hospital & Facility Services;
semi-private room rate **
$100 Copayment per Day up to 3 Days plus amounts that exceed the Reasonable and Allowed Charge$150 Copayment per Day up to 3 Days plus amounts that exceed the Reasonable and Allowed Charge$150 Copayment per Day up to 3 Days plus amounts that exceed the Reasonable and Allowed Charge30% Coinsurance ***
(Reference Based Pricing)
40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge
Psychiatrist & Psychologist Services10% Coinsurance after Annual Deductible10% Coinsurance after Annual Deductible15% Coinsurance after Annual Deductible15% Coinsurance after Annual Deductible20% Coinsurance after Annual Deductible20% Coinsurance after Annual Deductible30% Coinsurance ***20% Coinsurance after Annual Deductible20% Coinsurance after Annual Deductible
OUTPATIENT
Psychiatrist & Psychologist Services$10 Copayment per visit30% Coinsurance after Annual Deductible$20 Copayment per visit40% Coinsurance after Annual Deductible$25 Copayment per visit50% Coinsurance after Annual Deductible$60 co-pay ***30% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible
Psychological Testing **10% Coinsurance after Annual Deductible30% Coinsurance after Annual Deductible15% Coinsurance after Annual Deductible40% Coinsurance after Annual Deductible20% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible$60 co-pay ***30% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible
OTHER SERVICESParticipating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating Providers
(PHCS)
Participating ProvidersNon-Participating Providers (*)
Ambulance & Air Ambulance
** - (Non-emergent)
$150 Copayment plus amounts that exceed the Reasonable and Allowed Charge$200 Copayment plus amounts that exceed the Reasonable and Allowed Charge$250 Copayment plus amounts that exceed the Reasonable and Allowed Charge$300 co-pay ***
(Reference Based Pricing)
30% Ground / 50% Air Coinsurance after Annual Deductible
Chemotherapy **10% Coinsurance after Annual Deductible30% Coinsurance after Annual Deductible15% Coinsurance after Annual Deductible40% Coinsurance after Annual Deductible20% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible30% Coinsurance ***
(Reference Based Pricing)
30% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible
Dialysis and Supplies **10% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge15% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge20% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge30% Coinsurance ***
(Reference Based Pricing)
40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge
Home Health Services **
(Maximum of 120 visits per year)
10% Coinsurance after Annual Deductible30% Coinsurance after Annual Deductible15% Coinsurance after Annual Deductible40% Coinsurance after Annual Deductible20% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible$60 co-pay ***30% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible
Hospice Services **$20 Copayment per visit30% Coinsurance after Annual Deductible$30 Copayment per visit40% Coinsurance after Annual Deductible$35 Copayment per visit50% Coinsurance after Annual Deductible30% Coinsurance ***
(Reference Based Pricing)
30% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible
Physical/Occupational/Speech Therapy **
(Non Hospital Based)
10% Coinsurance after Annual Deductible30% Coinsurance after Annual Deductible$30 Copayment per visit40% Coinsurance after Annual Deductible$35 Copayment per visit50% Coinsurance after Annual Deductible$60 co-pay ***30% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible
ALTERNATIVE CARE SERVICESParticipating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating Providers
(PHCS)
Participating ProvidersNon-Participating Providers (*)
Acupuncture - Chiropractic Care
Naturopathy - Message Therapy
(Maximum of $400 per Calendar Year)
$20 Copayment per visit30% Coinsurance after Annual Deductible$30 Copayment per visit40% Coinsurance after Annual Deductible$35 Copayment per visit50% Coinsurance after Annual DeductibleNot Covered30% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible
PHARMACY BENEFITSParticipating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating Providers
(PHCS)
Participating ProvidersNon-Participating Providers (*)
Prescription Drugs
Pharmacy Retail
Up to a 31 day supply
Except prescribed contraceptive methods
Generic - $10 Copayment
Preferred Brand - $20 Copayment
Non-Preferred Brand - $35 Copayment
Generic - $20 Copayment
Preferred Brand - $30 Copayment
Non-Preferred Brand - $45 Copayment
Generic - $25 CopaymentGeneric - $25 Copayment
Preferred Brand - $40 Copayment
Non-Preferred Brand - $55 Copayment
Generic - $15 co-pay
Preferred Brand - $50 co-pay
Non-Preferred Brand - $50 co-pay
Generic - $25 co-pay
Preferred Brand - $50 co-pay
Non-Preferred Brand - $75 co-pay
Prescription Drugs
Pharmacy Retail
90 Day Supply
Generic - $30 Copayment
Preferred Brand - $60 Copayment
Non-Preferred Brand - $105 Copayment
Generic - $60 Copayment
Preferred Brand - $90 Copayment
Non-Preferred Brand - $130 Copayment
Generic - $75 Copayment
Preferred Brand - $120 Copayment
Non-Preferred Brand - $165 Copayment
Generic - $45 co-pay
Preferred Brand - $150 co-pay
Non-Preferred Brand - $150 co-pay
Generic - $75 co-pay
Preferred Brand - $150 co-pay
Non-Preferred Brand - $225 co-pay
Prescription Drugs
Pharmacy Mail Order
90 Day Supply
Generic - $20 Copayment
Preferred Brand - $40 Copayment
Non-Preferred Brand - $70 Copayment
Generic - $40 Copayment
Preferred Brand - $60 Copayment
Non-Preferred Brand - $90 Copayment
Generic - $50 Copayment
Preferred Brand - $80 Copayment
Non-Preferred Brand - $110 Copayment
Generic - $30 co-pay
Preferred Brand - $100 co-pay
Non-Preferred Brand - $100 co-pay
Generic - $50 co-pay
Preferred Brand - $100 co-pay
Non-Preferred Brand - $150 co-pay
VISION CARE SERVICESParticipating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating Providers
(PHCS)
Participating ProvidersNon-Participating Providers (*)
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$250 per year per covered member$250 per year per covered member$250 per year per covered member
Monthly Cost
Employee Only$360.00$348.00$335.00$275.00$317.00
Employee + Spouse$680.00$656.00$635.00$511.00$588.00
Employee + Child(ren)$620.00$595.00$573.00$470.00$545.00
Employee + Family$1,210.00$1,160.00$1,110.00$747.00$885.00

BENEFITSPremiumGold 1000Silver 2000Bronze 2000
Member PaysMember PaysMember PaysMember PaysMember PaysMember PaysMember PaysMember Pays
PLAN PROVISIONSParticipating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)
Annual Deductible$500 / Person
$1,500 / Family
$1,000 / Person
$3,000 / Family
$1,000 / Person
$3,000 / Family
$2,000 / Person
$6,000 / Family
$2,000 / Person
$6,000 / Family
$4,000 / Person
$12,000 / Family
$2,000 / Person
$6,000 / Family
$4,000 / Person
$12,000 / Family
Annual Out-of-Pocket
(Deductible, Copayment and Coinsurance)
$1,000 / Person
$3,000 / Family
$2,000 / Person
$6,000 / Family
$2,000 / Person
$6,000 / Family
$4,000 / Person
$12,000 / Family
$4,000 / Person
$12,000 / Family
$8,000 / Person
$24,000 / Family
$6,600 / Person
$13,200 / Family
$8,000 / Person
$24,000 / Family
Lifetime MaximumNoneNoneNoneNone
MEDICAL SERVICES
PHYSICIAN SERVICESParticipating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)
Physician Office Visits
(including Specialist)
$10 Copayment per visit30% Coinsurance after Annual Deductible$20 Copayment per visit40% Coinsurance after Annual Deductible$25 Copayment per visit50% Coinsurance after Annual Deductible$25 Copayment per visit50% Coinsurance after Annual Deductible
Other Physician Services performed in the office or a Facility including Maternity10% Coinsurance after Annual Deductible30% Coinsurance after Annual Deductible15% Coinsurance after Annual Deductible40% Coinsurance after Annual Deductible20% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible30% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible
Urgent Care$20 Copayment per visit30% Coinsurance after Annual Deductible$30 Copayment per visit40% Coinsurance after Annual Deductible$35 Copayment per visit50% Coinsurance after Annual Deductible$50 Copayment per visit50% Coinsurance after Annual Deductible
ImmunizationsNo Copayment30% Coinsurance after Annual DeductibleNo Copayment40% Coinsurance after Annual DeductibleNo Copayment50% Coinsurance after Annual DeductibleNo Copayment50% Coinsurance after Annual Deductible
PREVENTATIVE CAREParticipating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)
Well Child Care Office Visits - Immunizations - Lab TestsNo Copayment30% Coinsurance after Annual DeductibleNo Copayment40% Coinsurance after Annual DeductibleNo Copayment50% Coinsurance after Annual DeductibleNo Co-pay50% Coinsurance after Annual Deductible
Physical Exam - Prostate Exam - Screenings - CounselingNo Copayment30% Coinsurance after Annual DeductibleNo Copayment40% Coinsurance after Annual DeductibleNo Copayment50% Coinsurance after Annual DeductibleNo Co-pay50% Coinsurance after Annual Deductible
Well Women Exams - Pap Smears - MammographyNo Copayment30% Coinsurance after Annual DeductibleNo Copayment40% Coinsurance after Annual DeductibleNo Copayment50% Coinsurance after Annual DeductibleNo Co-pay50% Coinsurance after Annual Deductible
HOSPITAL / FACILITY SERVICESParticipating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)
Inpatient Room & Care
(Semi-private room rate) **
$100 copay, 10% after ded.$100 copay, 30% after ded.$100 copay, 15% after ded.$100 copay, 40% after ded.$100 copay, 20% after ded.$200 copay, 50% after ded.40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge *
Outpatient / Ambulatory Surgery Services & Birthing Centers **$100 copay, 10% after ded.$100 copay, 30% after ded.$100 copay, 15% after ded.$100 copay, 40% after ded.$100 copay, 20% after ded.$200 copay, 50% after ded.$400 Copayment plus amounts that exceed the Reasonable and Allowed Charge *
Other Outpatient Hospital Services ** - If at a hospital
(such as Cardiac, Pulmonary, PT/OT/ST)
$100 copay, 10% after ded.$100 copay, 30% after ded.$100 copay, 15% after ded.$100 copay, 40% after ded.$100 copay, 20% after ded.$200 copay, 50% after ded.40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge *
Emergency Room Services$100 copay, 10% after ded.$100 copay, 30% after ded.$100 copay, 15% after ded.$100 copay, 40% after ded.$100 copay, 20% after ded.$200 copay, 50% after ded.$500 Copayment plus amounts that exceed the Reasonable and Allowed Charge (waived if admitted to Inpatient status) *
DIAGNOSTIC SERVICESParticipating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)
Laboratory - Radiology - Scans (CT/MRI/PET)
Non Hospital BasedNo Copayment30% Coinsurance after Annual DeductibleNo Copayment40% Coinsurance after Annual DeductibleNo Copayment50% Coinsurance after Annual Deductible30% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible
Hospital Based **10% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge15% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge20% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge
MENTAL HEALTH
BEHAVIORAL HEALTH
SUBSTANCE ABUSE DISORDER
Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)
INPATIENT
Hospital & Facility Services;
semi-private room rate **
$100 Copayment per Day up to 3 Days plus amounts that exceed the Reasonable and Allowed Charge$150 Copayment per Day up to 3 Days plus amounts that exceed the Reasonable and Allowed Charge$150 Copayment per Day up to 3 Days plus amounts that exceed the Reasonable and Allowed Charge40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge
Psychiatrist & Psychologist Services10% Coinsurance after Annual Deductible10% Coinsurance after Annual Deductible15% Coinsurance after Annual Deductible15% Coinsurance after Annual Deductible20% Coinsurance after Annual Deductible20% Coinsurance after Annual Deductible20% Coinsurance after Annual Deductible20% Coinsurance after Annual Deductible
OUTPATIENT
Psychiatrist & Psychologist Services$10 Copayment per visit30% Coinsurance after Annual Deductible$20 Copayment per visit40% Coinsurance after Annual Deductible$25 Copayment per visit50% Coinsurance after Annual Deductible30% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible
Psychological Testing **10% Coinsurance after Annual Deductible30% Coinsurance after Annual Deductible15% Coinsurance after Annual Deductible40% Coinsurance after Annual Deductible20% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible30% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible
OTHER SERVICESParticipating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)
Ambulance & Air Ambulance
** - (Non-emergent)
$150 Copayment plus amounts that exceed the Reasonable and Allowed Charge$200 Copayment plus amounts that exceed the Reasonable and Allowed Charge$250 Copayment plus amounts that exceed the Reasonable and Allowed Charge30% Ground / 50% Air Coinsurance after Annual Deductible
Chemotherapy **10% Coinsurance after Annual Deductible30% Coinsurance after Annual Deductible15% Coinsurance after Annual Deductible40% Coinsurance after Annual Deductible20% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible30% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible
Dialysis and Supplies **10% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge15% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge20% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge
Home Health Services **
(Maximum of 120 visits per year)
10% Coinsurance after Annual Deductible30% Coinsurance after Annual Deductible15% Coinsurance after Annual Deductible40% Coinsurance after Annual Deductible20% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible30% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible
Hospice Services **$20 Copayment per visit30% Coinsurance after Annual Deductible$30 Copayment per visit40% Coinsurance after Annual Deductible$35 Copayment per visit50% Coinsurance after Annual Deductible30% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible
Physical/Occupational/Speech Therapy **
(Non Hospital Based)
10% Coinsurance after Annual Deductible30% Coinsurance after Annual Deductible$30 Copayment per visit40% Coinsurance after Annual Deductible$35 Copayment per visit50% Coinsurance after Annual Deductible30% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible
ALTERNATIVE CARE SERVICESParticipating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)
Acupuncture - Chiropractic Care
Naturopathy - Message Therapy
(Maximum of $400 per Calendar Year)
$20 Copayment per visit30% Coinsurance after Annual Deductible$30 Copayment per visit40% Coinsurance after Annual Deductible$35 Copayment per visit50% Coinsurance after Annual Deductible30% Coinsurance after Annual Deductible50% Coinsurance after Annual Deductible
PHARMACY BENEFITSParticipating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)
Prescription Drugs
Pharmacy Retail
Up to a 31 day supply
Except prescribed contraceptive methods
Generic - $10 Copayment
Preferred Brand - $20 Copayment
Non-Preferred Brand - $35 Copayment
Generic - $20 Copayment
Preferred Brand - $30 Copayment
Non-Preferred Brand - $45 Copayment
Generic - $25 CopaymentGeneric - $25 Copayment
Preferred Brand - $40 Copayment
Non-Preferred Brand - $55 Copayment
Generic - $25 co-pay
Preferred Brand - $50 co-pay
Non-Preferred Brand - $75 co-pay
Prescription Drugs
Pharmacy Retail
90 Day Supply
Generic - $30 Copayment
Preferred Brand - $60 Copayment
Non-Preferred Brand - $105 Copayment
Generic - $60 Copayment
Preferred Brand - $90 Copayment
Non-Preferred Brand - $130 Copayment
Generic - $75 Copayment
Preferred Brand - $120 Copayment
Non-Preferred Brand - $165 Copayment
Generic - $75 co-pay
Preferred Brand - $150 co-pay
Non-Preferred Brand - $225 co-pay
Prescription Drugs
Pharmacy Mail Order
90 Day Supply
Generic - $20 Copayment
Preferred Brand - $40 Copayment
Non-Preferred Brand - $70 Copayment
Generic - $40 Copayment
Preferred Brand - $60 Copayment
Non-Preferred Brand - $90 Copayment
Generic - $50 Copayment
Preferred Brand - $80 Copayment
Non-Preferred Brand - $110 Copayment
Generic - $50 co-pay
Preferred Brand - $100 co-pay
Non-Preferred Brand - $150 co-pay
VISION CARE SERVICESParticipating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)Participating ProvidersNon-Participating Providers (*)
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$250 per year per covered member$250 per year per covered member
Monthly Cost
Employee Only$360.00$348.00$335.00$317.00
Employee + Spouse$680.00$656.00$635.00$588.00
Employee + Child(ren)$620.00$595.00$573.00$545.00
Employee + Family$1,210.00$1,160.00$1,110.00$885.00

CALCULATE Monthly Plan Costs

* – Coinsurance amount is based on an approved Reasonable and Allowed reimbursement 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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