Health Plan Overview Page 3
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3Health Plan Comparison Sheet
Service and coSt
health choice
Super health
Emergency Room
$25 co-pay
90% of approved amount after deductible
100% of approved amount for accidental
injury
Urgent Care
IN NETWORK: $10 co-pay; 100% for initial
90% of approved amount after deductible
exam for accident/medical emergency
OUT OF NETWORK: 80% of approved amount
after deductible, 100% of approved amount for
initial exam for accident/medical emergency
Surgery
IN NETWORK: 100% of approved amount
100% of approved amount
OUT OF NETWORK: 80% of approved
amount after deductible
Hospital Care
IN NETWORK: 100% of approved amount
100% of approved amount plus $5 per
OUT OF NETWORK: 80% of approved
day for private room
amount after deductible
Prescriptions
IN NETWORK: Co-pay $5 generic/$10 brand
Co-pay $5 generic/brand
OUT OF NETWORK: 75% of approved amount
Physician Office Visit
IN NETWORK: $5 co-pay; 100% approved
90% of approved amount after deductible;
amount for initial exam for injury/medical
100% for accidental injury
emergency
OUT OF NETWORK: 80% of approved
amount after deductible; 100% approved
amount for initial exam for injury/medical
emergency
Vision
IN NETWORK: $10 co-pay for one exam per
90% of approved amount after deductible
calendar year
OUT OF NETWORK: 80% of approved
amount after deductible
Deductible
IN NETWORK: None
$250 per calendar year
OUT OF NETWORK: $250 individual per
calendar year
Maximum Out of Pocket
IN NETWORK: None
100% after payments reach $1,000
OUT OF NETWORK: 100% after payments
reach $2,500
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