10 2025 Medical Plans At-a-Glance 1) The family deductible must be met before any person receives benefits. 2) After calendar year deductible. 3) Calendar year deductible waived. 4) As specified in the essential drug list. PLAN FEATURE CENTIVO PCP PARTNERSHIP PLAN (So Cal, Denver, CO, Dallas, TX, Kansas City, KS and MO, Seattle & Spokane, WA) VALUE COPAY PLAN NETWORK ONLY YOU PAY NETWORK ONLY YOU PAY Employee Paycheck Contributions $ $ Preventive Care Covered in full3 Covered in full3 Telemedicine Doctor Visit Behavioral Health Visit Through Centivo Virtual Primary Care FREE N/A Through Teladoc $5 copay $5 copay Telemedicine (text-based) Doctor Visit N/A Through 98point6 FREE Calendar Year Deductible Employee Only / Family In-network Employee Only / Family Out-of-nework $1,000 / $2,000 N/A $5,000 / $10,0001 N/A Coinsurance (You Pay) N/A 20% Calendar Year Out-of-Pocket Maximum Employee Only / Family $4,000 / $8,000 $7,0006 / $14,0006 Health Savings Account (HSA) N/A N/A PCP Office Visit FREE $20 copay Specialist Office Visit $50 copay $75 copay Urgent Care $75 copay $75 copay Emergency Room $500 copay $500 copay2,7 then you pay 30% Diagnostic Testing $20 copay 20%2 Outpatient X-ray and Lab $20 copay 20%2 Hospitalization Inpatient Semi-Private Room Inpatient Physician $900 copay after deductible Included with copay above 20%2 20%2 Outpatient Treatment (PT, OT, ST) Hinge Health Virtual Physical Therapy $50 copay FREE 20%2 FREE Mental Health/Substance Abuse Inpatient Outpatient $900 copay after deductible FREE 20%2 $45 copay Pharmacy Retail Specified Preventive Drugs4 Generic Brand Formulary Brand Non-Formulary Specialty Drugs 30-day supply10 (see footnote) 100% covered3/$5 copay13 $10 copay3 $25 copay2 $40 copay2 20%2,8 up to $125 30-day supply10 (see footnote) 100% covered3/$5 copay13 $10 copay3 $25 copay2 $40 copay2 20%2,8 up to $125 Pharmacy Mail Service Specified Preventive Drugs4 Generic Brand Formulary Brand Non-Formulary 90-day supply 100% covered3/$10 copay13 $20 copay3 $50 copay2 $80 copay2 90-day supply 100% covered3/$10 copay13 $20 copay3 $50 copay2 $80 copay2 5) In-network calendar year deductible is separate from out-of-network calendar year deductible and does not cross accumulate. Refer to the Summary of Benefits and Coverage (SBC) for the plan for information on out-of-network deductible amounts on www.ensignbenefits.com. 6) In-network calendar year out-of-pocket maximum is separate from out-of-network calendar year out-ofpocket maximum and does not cross accumulate. Refer to the Summary of Benefits and Coverage (SBC) for the plan for information on out-of-network out-of-pocket maximum amounts on www.ensignbenefits.com.
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