2024-Framebridge-Benefit Guide

MEDICAL BENEFITS

ARCHES

SHENANDOAH

YOSEMITE HSA

MEDICAL BENEFIT

IN-NETWORK

OUT-OF-NETWORK

IN-NETWORK

OUT-OF-NETWORK

IN-NETWORK ONLY

Annual Deductible

Individual: None Family: None

Individual: $1,000 Family: $2,000 Individual: $6,000 Family: $12,000

Individual: $500 Family: $1,000

Individual: $1,000 Family: $2,000 Individual: $6,000 Family: $12,000

Individual: $2,500 Family: $5,000** Individual: $5,000 Family: $6,850

Annual Out-of-Pocket Maximum

Individual: $3,000 Family: $6,000

Individual: $3,000 Family: $6,000

Coinsurance

UHC 100% / EE 0%

UHC 80% / EE 20%

UHC 90% / EE 10%

UHC 80% / EE 20%

Unlimited

Preventive Care

No charge

20% after deductible

No charge

20% after deductible

No charge

Outpatient Care Primary care physician office visits Specialist office visits

$15 copay $30 copay

20% after deductible 20% after deductible

$30 copay $50 copay

20% after deductible 20% after deductible

20% after deductible 20% after deductible

Outpatient Laboratory Outpatient X-Ray

No charge 1

No charge 1

20% after deductible 1

20% after deductible

20% after deductible**

Advanced Radiology (MRI, MRA, CAT & Pet Scan) Emergency Care Hospital emergency room (waived if admitted) Urgent care

$150 copay 1

$150 copay 1

20% after deductible 1

20% after deductible

20% after deductible**

$150 copay

$150 copay

$350 copay

$350 copay*

20% after deductible

$75 copay

20% after deductible

$75 copay

20% after deductible**

20% after deductible

Hospital Care Inpatient Outpatient surgery

No charge No charge

20% after deductible 20% after deductible

10% after deductible 10% after deductible

20% after deductible** 20% after deductible**

20% after deductible 20% after deductible

Mental Health Inpatient Outpatient

No charge $30 copay

20% after deductible 20% after deductible

10% after deductible $50 copay

20% after deductible** 20% after deductible**

20% after deductible 20% after deductible

Plan Deductible Applies Ind $2,500/Fam $5,000 $10 / $35 / $70

Prescription Drug Deductible Retail Pharmacy (30 day supply) Tier 1/Tier 2/Tier 3 Mail Order (90 day supply) Tier 1/Tier 2/Tier 3

$10 / $35 / $70

$10 / $35 / $70

$10 / $35 / $70

$10 / $35 / $70

$25 / $87.50 / $175

$25 / $87.50 / $175

In-Network Only

$25 / $87.50 / $175

In-Network Only

Medical Contributions Per Pay Period Employee Only Employee + Spouse Employee + Child(ren) Employee + Family

$81.85 $279.30 $211.17 $406.81

$37.71 $230.99 $172.98 $322.70

$24.23 $148.43 $111.16 $207.36

1. For Designated Network Providers

*Notification is required if confined in an Out-0f-Network hospital **Prior Authorization required

***Plan pays benefits only after one or more family members satisfies the family deductible.

For additional information, please refer to your detailed plan summary. In the event of a discrepancy, the carrier Plan Document shall prevail.

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