Scott Appalachian Industries Medical Benefits
Summary of Medical Benefits
PPO 7
| In-Network | Out-Of-Network | |
|---|---|---|
| Plan Year Deductible | $1,000 Individual/ $2,000 Family |
$2,000 Individual/ $4,000 Family |
| Plan Year Out of Pocket | $6,000 Individual/ $12,000 Family |
$12,000 Individual/ $24,000 Family |
| Primary Care Office Visit | $20 Copay | 50% After Deductible |
| Specialist Office Visit | $50 Copay | 50% After Deductible |
| Preventive Care/Screenings/Immunization | Covered at 100% | 50% Deductible waived |
| Diagnostic Testing: Lab, X-Ray | 0% After Deductible 20% After Deductible |
50% After Deductible |
| Complex Imagining (MRI, PET/CT) | 20% After Deductible | 50% After Deductible |
| Outpatient Surgery | 20% After Deductible | 50% After Deductible |
| Inpatient Hospital | 20% After Deductible | 50% After Deductible |
| Urgent Care | $40 Copay | 50% After Deductible |
| Emergency Room | $300 After Deductible | $300 After Deductible |
| Rehabilitation Services (PT/OT/SP)-Limit 30 visits | $50 Copay After Deductible | 50% After Deductible |
| Pharmacy | ||
|---|---|---|
| RX Deductible | Integrated with Medical | |
| Retail (30 Day Supply) | Generic - $10 Copay Preferred Brand - $25 Copay Non-Preferred Brand - 50% Coinsurance Specialty Drugs - $200 Copay |
|
| Mail Order (90 Day Supply) | Generic - $20 Copay Preferred Brand - $50 Copay Non-Preferred Brand - 50% Coinsurance |
|
| Out of Network Pharmacy | ||
|---|---|---|
| Plan Year Deductible | Not Covered | |
| Member Coinsurance | Not Covered | |
| Plan Year Out of Pocket | Not Covered | |
PPO 9
| In-Network | Out-Of-Network | |
|---|---|---|
| Plan Year Deductible | $3,000 Individual/ $6,000 Family |
$5,000 Individual/ $10,000 Family |
| Plan Year Out of Pocket | $6,750 Individual/ $13,500 Family |
$15,000 Individual/ $30,000 Family |
| Primary Care Office Visit | $20 Copay | 50% After Deductible |
| Specialist Office Visit | $50 Copay | 50% After Deductible |
| Preventive Care/Screenings/Immunization | Covered at 100% | 50% Deductible waived |
| Diagnostic Testing: Lab, X-Ray | 0% After Deductible 20% After Deductible |
50% After Deductible |
| Complex Imagining (MRI, PET/CT) | 20% After Deductible | 50% After Deductible |
| Outpatient Surgery | 20% After Deductible | 50% After Deductible |
| Inpatient Hospital | 20% After Deductible | 50% After Deductible |
| Urgent Care | $40 Copay | 50% After Deductible |
| Emergency Room | $300 After Deductible | $300 After Deductible |
| Rehabilitation Services (PT/OT/SP)-Limit 30 visits | $50 Copay | 50% After Deductible |
| Pharmacy | ||
|---|---|---|
| RX Deductible | Integrated with Medical | |
| Retail (30 Day Supply) | Generic - $10 Copay Preferred Brand - $25 Copay Non-Preferred Brand - 50% Coinsurance Specialty Drugs - $200 Copay |
|
| Mail Order (90 Day Supply) | Generic - $20 Copay Preferred Brand - $50 Copay Non-Preferred Brand - 50% Coinsurance |
|
| Out of Network Pharmacy | ||
|---|---|---|
| Plan Year Deductible | Not Covered | |
| Member Coinsurance | Not Covered | |
| Plan Year Out of Pocket | Not Covered | |
PPO 11
| In-Network | Out-Of-Network | |
|---|---|---|
| Plan Year Deductible | $6,000 Individual/ $12,000 Family |
$10,000 Individual/ $20,000 Family |
| Plan Year Out of Pocket | $8,000 Individual/ $16,000 Family |
$20,000 Individual/ $40,000 Family |
| Primary Care Office Visit | $20 Copay | 50% After Deductible |
| Specialist Office Visit | $50 Copay | 50% After Deductible |
| Preventive Care/Screenings/Immunization | Covered at 100% | 50% Deductible waived |
| Diagnostic Testing: Lab, X-Ray | 0% After Deductible for lab tests at independent facility 30% After Deductible |
50% After Deductible |
| Complex Imagining (MRI, PET/CT) | 30% After Deductible | 50% After Deductible |
| Outpatient Surgery | 30% After Deductible | 50% After Deductible |
| Inpatient Hospital | 30% After Deductible | 50% After Deductible |
| Urgent Care | $40 Copay | 50% After Deductible |
| Emergency Room | 30% After Deductible | 30% After Deductible |
| Rehabilitation Services (PT/OT/SP)-Limit 30 visits | 30% After Deductible | 50% After Deductible |
| Pharmacy | ||
|---|---|---|
| RX Deductible | Integrated with Medical | |
| Retail (30 Day Supply) | Generic - $10 Copay Preferred Brand - $25 Copay Non-Preferred Brand - 50% Coinsurance Specialty Drugs - $200 Copay |
|
| Mail Order (90 Day Supply) | Generic - $20 Copay Preferred Brand - $50 Copay Non-Preferred Brand - 50% Coinsurance |
|
| Out of Network Pharmacy | ||
|---|---|---|
| Plan Year Deductible | Not Covered | |
| Member Coinsurance | Not Covered | |
| Plan Year Out of Pocket | Not Covered | |
To learn more about your plan, please review your Summary of Benefits and Coverage (SBC) for a high-level overview of your coverage or the Summary Plan Document (SPD) for the detailed plan description and guidelines
Important Plan Documents