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Services

HSA Plan

Network

Non-Network

PPO 750

Network

Non-Network

PPO 1250

Network

Non-Network

Services

HSA Plan

Network

Non-Network

PPO 750

Network

Non-Network

PPO 1250

Network

Non-Network

Coinsurance and/or Copayments

HSA Plan


Network

20% coinsurance after deductible for most services

Separate coinsurance applies to prescriptions

See plan page for details

Non-Network

40% coinsurance after deductible for most services

Separate coinsurance applies to prescriptions

See plan page for details

PPO 750


Network

20% coinsurance after deductible for most services

Copayments apply to Emergency Room and prescriptions

See plan page for details

Non-Network

40% coinsurance after deductible for most services.

Copayments apply to Emergency Room and prescriptions

See plan page for details

PPO 1250


Network

20% coinsurance after deductible for most services

Copayments apply to Emergency Room, office visits and prescriptions

See plan page for details

Non-Network

40% coinsurance after deductible for most services

Copayments apply to Emergency Room, office visits and prescriptions

See plan page for details

Deductible
  Individual
  Family

HSA Plan


Network
Individual: $1,650
Family: $3,300


Non-Network
Individual: $3,300
Family: $6,600

PPO 750


Network
Individual: $   750
Family: $1,500


Non-Network
Individual: $1,500
Family: $3,000

PPO 1250


Network
Individual: $1,250
Family: $2,500


Non-Network
Individual: $2,500
Family: $5,000

Medical OOP Maximum
  Individual
  Family

HSA Plan


Network
Individual: $4,950
Family: $9,900*


Non-Network
Individual: $9,900
Family: $19,800

PPO 750


Network
Individual: $2,250
Family: $4,500


Non-Network
Individual: $4,500
Family: $9,000

PPO 1250


Network
Individual: $3,750
Family: $7,500


Non-Network
Individual: $7,500
Family: $15,000

Prescription OOP Maximum
  Individual
  Family

HSA Plan


Network
Combined with Medical


Non-Network
Combined with Medical

PPO 750


Network
Individual: $4,150
Family: $8,300


Non-Network
No Maximum

PPO 1250


Network
Individual: $4,150
Family: $8,300


Non-Network
No Maximum

* Any individual family member need only incur a maximum of seven thousand nine hundred dollars ($7,900) before the plan begins paying one hundred percent (100%) of covered charges for that individual.

All three of MCHCP’s medical plans offer the same benefits, such as:

  • 100% coverage of preventive care — such as preventive exams, vaccinations recommended by the Advisory Committee for Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), age-specific screenings and much more — when using a network provider.
  • Your choice of health care providers, pharmacies and hospitals from a nationwide network, usually at a lower cost to you.

While the benefits are the same in all three medical plans, premium, deductible and out-of-pocket (OOP) costs vary. Because each member has different medical needs, the best plan choice may differ from person to person. Take the time to consider your situation and review the plans closely. It may help determine which plan is the right fit for you. (See also: Non-Contraception Benefit Option.)

The member pays the deductible, copayments and coinsurance amounts until OOP maximum is reached. There are separate deductibles and OOP maximums for network and non-network services.

For more detailed plan information, visit the individual plan page:



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