burpee_guide

PLAN NAME

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

Annual Deductible

Individual: $000; Family: $000

Out-of-Pocket Maximum

Individual: $000 Family: $000

Individual: $000 Family: $000

Lifetime Maximum

$000

Preventive Care Adult Preventive Care Adult Annual Physical Exam Well-Child Care

000% 000% 000%

000% 000% 000%

•

Outpatient Care Primary care physician office visits Specialist office visits Outpatient facility surgery Outpatient Lab & X-Ray Initial visit, and all subsequent visits Emergency Care Ambulance when medically necessary At hospital emergency room Urgent Care Maternity Care Prenatal and Post-natal care Hospital services for mother and child

$00 $00 $00

00%* 00%* 00%*

•

•

00%

00%*

•

$00 $00 $00

$00* $00* $00*

000%* 000%*

000%* 00%*

Mental Health Inpatient Outpatient

000%* 000%*

00%* 00%*

Prescription Drugs Retail Pharmacy (30 day supply) Generic/Preferred Brand/Non-Preferred Brand Mail Order (30 day supply) Generic/Preferred Brand/Non-Preferred Brand

$00/$00/$00

$00/$00/$00

$00/$00/$00

$00/$00/$00

Bi-Weekly Contributions Employee Only Employee + Spouse Employee + Children Employee + Family

$00.00 $00.00 $00.00 $00.00

$00.00 $00.00 $00.00 $00.00

* after deductible

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