| |
Benefits |
Evolve Plus |
Evolve Core |
Evolve HSA |
Evolve HSA 100 |
| |
Annual
Deductible
PCY; per individual
with a family max of three (choose one) |
$1,000 / $2,500 / $5,000 or $7,500 |
$2,500 / $5,000 or $7,500 /
$10,000 |
Single: $2,000 or $3,500
Family: $4,000 or $7,000 |
Single: $5,000
Family: $10,000 |
| |
Coinsurance
(what you pay) |
20% |
30% |
Choose either: 20% or 50% |
0% |
| |
Annual Coinsurance
Maximum
(PCY, family max of
three; once met, preferred
providers covered in full; deductible not included) |
$5,500
per person
$16,500 per family |
$7,500
per person
$22,500 per family |
Single: $5,000
Family: $10,000
(includes deductible) |
Single: $5,000
Family: $10,000
(includes deductible) |
| |
Annual Maximum |
$2
Million |
$2
Million |
$2
Million |
$2
Million |
| |
Preventive Care and Immunizations |
Deductible Waived;
Covered 100% |
Deductible Waived;
Covered 100% |
Deductible Waived;
Covered 100% |
Deductible Waived;
Covered 100% |
| |
Office Visits (Injury and Illness)
First four visits per calendar year; not subject
to deductible. |
Deductible Waived on 1st 4
Visits, $25 Copay;
(additional visits subject to
deductible, then 20%) |
Deductible Waived on 1st 4
Visits, $35 Copay;
(additional visits subject to
deductible, then 30%) |
Deductible
and Coinsurance |
Deductible
and 0% Coinsurance |
| |
Outpatient Radiology & Lab Services
(limit does not apply to preventive care or
complex outpatient imaging) |
First $400 PCY, not subject
to deductible |
First $200 PCY, not subject
to deductible |
Deductible and Coinsurance |
Deductible and 0%
Coinsurance |
| |
Complex Outpatient Imaging
(CT Scan,
MRI, PET, MRA, SPECT, Bone Density) |
Deductible, then 50% |
Deductible, then 50%
$1500 PCY maximum |
Deductible, then 50% |
Deductible and 0%
Coinsurance |
| |
After the up-front benefits
are exhausted
(Office visits, lab &
radiology) |
Deductible, then 20% |
Deductible, then 30% |
Deductible and Coinsurance |
Deductible and 0%
Coinsurance |
| |
Hospital
Inpatient/Outpatient |
Deductible, then 20% |
Deductible, then 30% |
Deductible and Coinsurance |
Deductible and 0%
Coinsurance |
| |
Maternity Care
(including prenatal care) |
Deductible, then 20% |
Not Covered |
Not Covered |
Not Covered |
| |
Emergency Services (Worldwide coverage) |
$100 copay,
then subject
to deductible, then 20%.
(copay waived if
admitted) |
$150 copay,
then subject
to deductible, then 30%.
(copay waived if
admitted) |
Deductible
and Coinsurance |
Deductible
and 0% Coinsurance
|
| |
Rehabilitation
Inpatient: 10
days PCY
Outpatient: 25 visits PCY |
Deductible, then
20% |
Deductible, then
30% |
Deductible
and Coinsurance |
Deductible
and 0% Coinsurance |
| |
Skilled
Nursing Facility 30 Inpatient days PCY |
Deductible, then 20% |
Deductible, then 30% |
Deductible and Coinsurance |
Deductible and 0%
Coinsurance |
| |
Home Health & Hospice
Home Health - 130 visits PCY
Hospice - Respite
care limited to 14 days in/outpatient per lifetime |
Deductible, then
20% |
Deductible, then
30% |
Deductible
and Coinsurance |
Deductible
and 0% Coinsurance |
| |
Acupuncture Services
6 visits PCY |
Deductible, then 20% |
Deductible, then 30% |
Deductible and Coinsurance |
Deductible and 0%
Coinsurance |
| |
Spinal Manipulations
10 visits PCY |
Deductible, then 20% |
Deductible, then 30% |
Deductible and Coinsurance |
Deductible and 0%
Coinsurance% |
| |
Vision Care
Routine eye exam & hardware covered to a combined
$150 PCY max. |
Deductible Waived, then 20% |
Not Covered |
Not Covered |
Not Covered |
| |
Mental
Health Treatment |
Deductible, then
20% |
Deductible, then
30% |
Deductible
and Coinsurance |
Deductible
and 0% Coinsurance |
| |
Prescription Drugs
|
Generics: $10 copay
Brand-Formulary:
$500 Deductible, then 50% |
Not Covered
(**Pharmacy discount program available) |
Generics Only: Deductible
and Coinsurance (**Pharmacy discount program available) |
Generics Only: Deductible
and 0% Coinsurance (**Pharmacy discount program available) |
| |
Transplants
(12 month waiting period) |
Deductible, then 20% |
Deductible, then 30% |
Deductible and Coinsurance |
Deductible and 0%
Coinsurance |
| |
24 Hour
Coverage (when enrollee is not entitled
to receive Worker's Compensation) |
Yes |
Yes |
Yes |
Yes |
