Complete Personnel Logistics: Health Insurance

March 5, 2021

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	HEALTH INSURANCE: SILVER

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Major Medical Benefits	Network	Non-Network
Individual Family	$750 $1,500	$1,500 $3,000
Co-Insurance	90% / 10%	50% / 50%
Out-of-Pocket (including deductable) Individual Family	$2,000 $4,000	Unlimited Unlimited
Inpatient Hospital Care	90% / 10% after deductable	50% / 50% after deductable
Emergency Room Treatment (Limited to severe medical condition)	$100 co-pay	50% / 50% after deductable
Outpatient Hospital Care	90% / 10% after deductable	50% / 50% after deductable
Office Visits	100% after $20 co-pay	50% / 50% after deductable
Inpatient Maternity Care	90% / 10% after deductable	50% / 50% after deductable
Lab and X-Ray	90% / 10% after deductable	50% / 50% after deductable
Therapy Services (limited to 10 visits per year)	90% / 10% after deductable	50% / 50% after deductable
Life Insurance	$10,000 Term
Urgent Care	$40 co-pay
Lifetime Maximum	$1,000,000
Retail Prescription Drugs ($3,000 annual limit) (30-day supply)	$20 generic / $30 name brand formulary $45 name brand non-formulary
Mail Order Prescription Drugs (Mandatory for prescriptions in excess of a 90-day supply)	$40 generic / $60 name brand formulary $90 name brand non-formulary

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This summary is intended to highlight your healthcare benefits and is not a contract of insurance. Please refer to your Summary Plan Description for a complete explanation of covered services, limitations, exclusions and a description of all terms and conditions of coverage.