Value Option Plan

Benefits at a Glance

BENEFIT DESCRIPTION	YOU PAY
BENEFIT DESCRIPTION	In-Network	Out-of-Network
Preventive Care
Annual Routine Physical Exam (age 3 or older)	Nothing	50% after deductible is met*
Adult Routine Immunizations & Tests	Nothing	50% after deductible is met*
Well Child Care (through age 2)	Nothing	50% after deductible is met*
Routine Immunizations (through age 21)	Nothing	50% after deductible is met*
Inpatient Hospital Care (precertification required)
Maternity	20% after deductible is met	50% after deductible is met*
Medical/Surgery Room and Board Other Services and Supplies	20% after deductible is met	50% after deductible is met*
Mental Health/Substance Abuse Room & Board Other Services and Supplies	20% after deductible is met	50% after deductible is met*
Outpatient Hospital Care
Medical/surgical	20% after deductible is met	50% after deductible is met*
Emergency Medical	20% after deductible is met	20% after deductible is met*
Chiropractic Care
Initial office visit and 12 office visits per calendar year when rendered on the same day as covered manipulations	20% after deductible is met	50% after deductible is met*
Manipulations (12 per calendar year)	20% after deductible is met	50% after deductible is met*
Physician Care
Office visits	20% after deductible is met	50% after deductible is met*
Telehealth professional services for minor acute conditions	10% after deductible is met	All charges
X-rays, other diagnostic services	20% after deductible is met	50% after deductible is met*
Laboratory Services	20% after deductible is met	50% after deductible is met*
Maternity Care (complete)	20% after deductible is met	50% after deductible is met*
Accidental Injury (nonsurgical care, simple laceration repair and immobilization of a sprain, strain, or fracture)	20% after deductible is met	50% after deductible is met*
Surgery	20% after deductible is met	50% after deductible is met*
Mental Health and Substance Abuse Care:
Office visit	20% after deductible is met	50% after deductible is met*
Outpatient telemental or virtual visits	10% after deductible is met	50% after deductible is met*
Other diagnostic services	20% after deductible is met	50% after deductible is met*
Laboratory Services	20% after deductible is met	50% after deductible is met*

Prescription Drugs This is a mandatory generic program	Network	Non-Network
Retail Pharmacy	1st and 2nd fill: $10 of generic cost (after deductible is met) $40 of Formulary brand cost (after deductible is met) $60 of Non-Formulary brand cost (after deductible is met) Note: You may purchase up to a 90-day supply (84-day minimum) of covered drugs and supplies at a CVS Caremark® Pharmacy or Longs Drugs through our Maintenance Choice Program. You will pay the applicable mail order copayment for each prescription purchased.	Full cost at time of purchase 50% after deductible is met*
Mail Order Program	90-day supply: $20 generic/$90 Formulary brand/$125 Non-Formulary brand (after deductible is met)
Specialty drugs (requires prior approval)	Caremark Specialty Pharmacy Mail Order: 30-day supply: $250 (after deductible is met) 90-day supply: $450 (after deductible is met)
Deductible
	In-Network	Out-of-Network
CDHP	Self - $2,000 Self and Family - $4,000	Self - $4,000 Self and Family - $8,000
Value Option	Self - $2,000 Self and Family - $4,000	Self - $4,000 Self and Family - $8,000
Catastrophic Limits
Medical/Surgical/Mental health and substance abuse care	In-Network providers/facilities, preferred network pharmacies or mail order pharmacy out-of-pocket maximum: Per person: $6,600 Per family: $13,200 Out-of-Network providers/facilities out-of-pocket maximum: Per person: $12,000 Per family: $24,000
*In addition, you are responsible for the difference, if any, between the Plan allowance and the billed amount.