Medical Benefits

Medical Plan Details

Benefit Summary

Consumer Choice 250

Consumer Choice 500

HSA-qualified
YES
YES
Deductible (medical and Rx combined)
Employee Only: $1,750
Family: $3,500 — True Family*
Employee Only: $3,000
Family: $6,000 — True Family*
Coinsurance
20%
20%
Out-of-pocket maximum (medical and Rx combined)
Employee Only: $3,500
Family: $7,000 — Embedded**
Employee Only: $6,000
Family: $12,000 — Embedded**

In-Network Services

In-Network Services

In-Network Services

PCP/specialist office visit
Deductible & Coinsurance
Deductible & Coinsurance
Telemedicine
$64 per medical visit until deductible is met, then 20% Coinsurance
$64 per medical visit until deductible is met, then 20% Coinsurance
Inpatient hospitalization
Deductible & Coinsurance
Deductible & Coinsurance
Outpatient surgery (facility)
Deductible & Coinsurance
Deductible & Coinsurance
Emergency room/urgent care
Deductible & Coinsurance
Deductible & Coinsurance

Out-of-Network Services

Out-of-Network Services

Out-of-Network Services

Deductible
Employee Only: $3,500
Family: $7,000 — True Family*
Employee Only: $6,000
Family: $12,000 — True Family*
Coinsurance
40%
40%
Out-of-pocket maximum
Employee Only: $7,000
Family: $14,000 — Embedded**
Employee Only: $12,000
Family: $24,000 — Embedded**

Health Savings Account — Employer Contribution

Health Savings Account — Employer Contribution

Health Savings Account — Employer Contribution

Employee HSA contributions will be 100% match by Momentive up to the following maximums:
Employee Only: $500
Family: $1,000
Employee Only: $1,000
Family: $2,000

*If you cover more than yourself, the family can meet the deductible by pooling deductible expenses together.

**The out-of-pocket maximum is the most you and your family will be responsible to pay out of pocket for services during the year. The single out-of-pocket maximum amount is embedded in the family out-of-pocket maximum. Therefore, when the deductible and coinsurance for one person reaches the individual out-of-pocket maximum, that individual is covered at 100% for the rest of the year. The family is capped at the family out-of-pocket maximum.

*If you cover more than yourself, the family can meet the deductible by pooling deductible expenses together.

**The out-of-pocket maximum is the most you and your family will be responsible to pay out of pocket for services during the year. The single out-of-pocket maximum amount is embedded in the family out-of-pocket maximum. Therefore, when the deductible and coinsurance for one person reaches the individual out-of-pocket maximum, that individual is covered at 100% for the rest of the year. The family is capped at the family out-of-pocket maximum.

*If you cover more than yourself, the family can meet the deductible by pooling deductible expenses together.

**The out-of-pocket maximum is the most you and your family will be responsible to pay out of pocket for services during the year. The single out-of-pocket maximum amount is embedded in the family out-of-pocket maximum. Therefore, when the deductible and coinsurance for one person reaches the individual out-of-pocket maximum, that individual is covered at 100% for the rest of the year. The family is capped at the family out-of-pocket maximum.

Don’t Forget

When you enroll in a Medical option, you will automatically have Critical Illness Insurance that pays a lump sum benefit of up to $2,500 per covered person for each diagnosed condition with a per-person lifetime maximum of $6,000.

Learn more

Pharmacy

EmpiRx Health manages all of your prescription needs. There are a number of programs that help control your costs. You and your dependents also have access to a board network of pharmacies, which includes all chain pharmacies and most independent pharmacies.

Vision

When you enroll in a Medical option, you will automatically be enrolled in Aetna Vision coverage. You can visit any licensed eye care provider.

Telemedicine

Amwell consults are $64 until your deductible is met. Please note Psychology or Psychiatry are based on a fee schedule; however, remember that our EAP offers up to a 8 free virtual or face-to-face therapy visits.

Sign in at MyHighmark.com.

If you are already registered, please make sure to update your insurance information (insuring entities and member ID’s) to ensure visits continue to be covered under the plan.