humphrys_coversports_guide
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COMPANY LOGO
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
$00.00 $00.00 $00.00 $00.00
$00.00 $00.00 $00.00 $00.00
Employee + Spouse Employee + Children Employee + Family
* after deductible
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COMPANY LOGO
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%
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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%*
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00%
00%*
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$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
$00.00 $00.00 $00.00 $00.00
$00.00 $00.00 $00.00 $00.00
Employee + Spouse Employee + Children Employee + Family
* after deductible
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COMPANY LOGO
BENEFIT
IN-NETWORK
OUT-OF-NETWORK
IN-NETWORK
Annual Deductible
Individual: $00 Family: $00
Individual: $00 Family: $00
Individual: $00 Family: $00
Benefit Maximum Annual Lifetime
$00 $00
$00 $00
00%
00%
00%
Diagnostic & Preventive Services Prophylaxis (Cleanings); Oral Examinations; Topical Fluoride; X-rays; Bitewing; Sealants (up to age 14); Space Maintainers Basic Services Fillings; Extractions; Oral Surgery; Endodontics; Periodontics; Periodontal surgery; Anesthesia; Consultations; Repairs of dentures, crowns, inlays and onlays Major Services Bridge and Dentures; Crowns, Inlays, Onlays, Implants
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00%
00%
00%
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00%
00%
00%
00%
00%
00%
Orthodontic Services (children only)
Bi-Weekly Contributions Employee Only Employee + Spouse Employee + Child(ren) Employee + Family
$000 $000 $000 $000
$000 $000 $000 $000
* after deductible
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COMPANY LOGO
BENEFIT
IN-NETWORK
OUT-OF-NETWORK
$00 copay
$00
Eye Exam
$00 copay
$00
Hardware (Frames and Lenses)
$00 $00 $00
$00 $00 $00
Frequency Exam
Lenses Frames
$00
$00
Frames
$00 $00 $00
$00 $00 $00
Lenses Single Vision Lenses Bifocal Vision Lenses Trifocal Vision Lenses
$00
$00
Medically Necessary/Elective Contact Lenses
Bi-Weekly Contributions Employee Only Employee + Spouse Employee + Child(ren) Employee + Family
$00 $00 $00 $00
$00 $00 $00 $00
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This benefit summary provides selected highlights of the employee benefits program available. It is not a legal document and shall not be construed as a guarantee of benefits nor of continued employment. All benefit plans are governed by master policies, contracts and plan documents. Any discrepancies between any information provided through this summary and the actual terms of such policies, contracts and plan documents shall be governed by the terms of such policies, contracts and plan documents. Our company reserves the right to amend, suspend or terminate any benefit plan, in whole or in part, at any time. The authority to make such changes rests with the Plan Administrator.
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