Your Medical Benefits
LocalPlus HDHPQ Plan - HDHPQ LocalPlus
Benefit Summary
Group # 00636233
A HDHP, or High Deductible Health Plan, can be combined with a tax-advantaged saving account allowing you to pay for certain medical expenses with money free from federal taxes. Until you reach your deductible, you must pay for most of your health care expenses out-of-pocket.
Note: The Plan deductible always applies before any benefit copay/deductible or coinsurance.
The LocalPlus® plan includes a local limited network and gives you cost-efficient access to quality doctors, specialists and hospitals – right where you live.
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Plan Documents
| In-Network | Out-of-Network | |
|---|---|---|
| Plan Name | LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
| Plan Coinsurance | Plan pays 100% | Plan pays 70% |
| Individual Deductible | Individual - Employee Only: $3,400 Individual - within a Family: $3,400 | Individual - Employee Only: $3,400 Individual - within a Family: $3,400 |
| Family Deductible | Family Maximum: $6,800 | Family Maximum: $6,800 |
| Individual Out-of-Pocket | Individual - Employee Only: $4,000 Individual - within a Family: $4,000 | Individual - Employee Only: $8,000 Individual - within a Family: $8,000 |
| Family Out-of-Pocket | Family Maximum: $8,000 | Family Maximum: $16,000 |
| Primary Care Office Visit | Plan pays 100% | Plan pays 70% |
| Specialist Care Office Visit | Plan pays 100% | Plan pays 70% |
| Emergency Room | Plan pays 100% | |
| Urgent Care | Plan pays 100% | Plan pays 70% |
| Outpatient Radiology | Plan pays 100% | Plan pays 70% |
| Independent Laboratory | Plan pays 100% | Plan pays 70% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | Plan pays 100% | Plan pays 70% |
| Pharmacy Formulary | Advantage | |
| Retail Pharmacy Customer Share | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $60 | Not Covered for all benefits |
| Home Delivery Pharmacy Customer Share | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $88 Non-Preferred Brand: You pay $150 | Not Covered for all benefits |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.
Benefit Summary
Group # 00636233
A HDHP, or High Deductible Health Plan, can be combined with a tax-advantaged saving account allowing you to pay for certain medical expenses with money free from federal taxes. Until you reach your deductible, you must pay for most of your health care expenses out-of-pocket.
Note: The Plan deductible always applies before any benefit copay/deductible or coinsurance.
The LocalPlus® plan includes a local limited network and gives you cost-efficient access to quality doctors, specialists and hospitals – right where you live.
| In-Network | Out-of-Network | |
|---|---|---|
| Plan Name | LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
| Plan Coinsurance | Plan pays 100% | Plan pays 70% |
| Individual Deductible | Individual - Employee Only: $3,400 Individual - within a Family: $3,400 | Individual - Employee Only: $3,400 Individual - within a Family: $3,400 |
| Family Deductible | Family Maximum: $6,800 | Family Maximum: $6,800 |
| Individual Out-of-Pocket | Individual - Employee Only: $4,000 Individual - within a Family: $4,000 | Individual - Employee Only: $8,000 Individual - within a Family: $8,000 |
| Family Out-of-Pocket | Family Maximum: $8,000 | Family Maximum: $16,000 |
| Primary Care Office Visit | Plan pays 100% | Plan pays 70% |
| Specialist Care Office Visit | Plan pays 100% | Plan pays 70% |
| Emergency Room | Plan pays 100% | |
| Urgent Care | Plan pays 100% | Plan pays 70% |
| Outpatient Radiology | Plan pays 100% | Plan pays 70% |
| Independent Laboratory | Plan pays 100% | Plan pays 70% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | Plan pays 100% | Plan pays 70% |
| Pharmacy Formulary | Advantage | |
| Retail Pharmacy Customer Share | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $60 | Not Covered for all benefits |
| Home Delivery Pharmacy Customer Share | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $88 Non-Preferred Brand: You pay $150 | Not Covered for all benefits |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.