| Plan 1 | Plan 2 | Plan 3 | Plan 4 | Plan 5 | Plan 6 | |
|---|---|---|---|---|---|---|
| Plan Name | MEC 2 | MEC 5 | MVP Bronze | MVP Gold | MVP Plus | MVP Ultra |
| Network | PHCS / Multiplan | PHCS / Multiplan | PHCS / Multiplan | PHCS / Multiplan | PHCS / Multiplan | PHCS / Multiplan |
| ACA Preventative Benefits | Included | Included | Included | Included | Included | Included |
| Virtual Medicine | Included | Included | Included | Included | Included | Included |
| Deductible | None | None | None | None | None | None |
| Maximum Out of Pocket | $7,350 | $7,350 | $7,350 | $5,000 | $2,000 | $2,000 |
| Inpatient Hospital Services | No Benefit | $350 Copay per admission(3 day limit) | $350 Copay per admission(5 day limit) | $350 Copay per admission(10 day limit) | $400 Copay | $400 Copay |
| Outpatient Hospital Services / Surgical | No Benefit | $350 Copay per admission(1 visit limit) | $350 Copay per admission(5 visit limit) | $350 Copay per admission(10 visit limit) | $400 Copay | $400 Copay |
| Maternity Inpatient | No Benefit | No Benefit | No Benefit | Included as in-patient hospital stay | $400 Copay | $400 Copay |
| Office Visits - PCP | $25 Copay - 2 visits per year | $25 Copay - 6 visits per year | $25 Copay - 8 visits per year | $15 Copay - 12 visits per year | $20 Copay | $20 Copay |
| Office Visits - Specialist | $50 Copay - 2 visits per year | $50 Copay - 6 visits per year | $50 Copay - 8 visits per year | $25 Copay - 12 visits per year | $20 Copay | $20 Copay |
| Lab / X-Ray | $50 Copay - 1 visit per year | $50 Copay - 3 visit per year | $50 Copay - 3 visit per year | $50 Copay - 4 visit per year | $50 Copay | $50 Copay |
| CT/MRI/MRA/PET Scan | No Benefit | $350 Copay - 1 visit per year | $350 Copay - 1 visit per year | $350 Copay - 3 visits per year | $400 Copay | $400 Copay |
| Urgent Care | $50 Copay - 2 visits per year | $50 Copay - 2 visits per year | $50 Copay - 2 visits per year | $35 Copay - 3 visits per year | $50 Copay | $50 Copay |
| Emergency Room | No Benefit | $350 Copay - 1 visit per year | $350 Copay - 1 visit per year | $350 Copay - 2 visits per year | $400 Copay | $400 Copay |
| Chemotherapy/Radiation | No Benefit | No Benefit | No Benefit | No Benefit | No Benefit | $400 Copay |
| Dialysis | No Benefit | No Benefit | No Benefit | No Benefit | No Benefit | $400 Copay |
| Colonoscopy | No Benefit | No Benefit | No Benefit | No Benefit | No Benefit | $400 Copay |
| Prescriptions | Generic Drugs - $10 Copay | Generic Drugs - $10 Copay | Generic Drugs - $10 Copay | Generic & Limited Brand 20% | Copays Generic: $10 Brand: $40 |
Copays Generic: $10 Brand: $40 Non Pref: $80 |
| This is general benefit information and should not be constituted as a guarantee of coverage or a level of benefit. Participants must follow plan rules to get the most from the plan. See policy or SBC for detailed coverage. | ||||||
| Monthly Rates | ||||||
| Single | $127.68 | $277.81 | $315.06 | $374.01 | $488.02 | $561.99 |
| EE + Spouse | $189.70 | $487.59 | $545.52 | $675.23 | $809.24 | $867.11 |
| EE + Child(ren) | $169.02 | $417.66 | $468.70 | $574.82 | $667.75 | $714.11 |
| Family | $231.04 | $627.43 | $699.17 | $876.04 | $978.81 | $1054.44 |