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EMPLOYEE BENEFITS / MEDICAL

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			Tri-County Schools Insurance Group Summary of Benefits
ACA Metal Ranking	Platinum	Platinum	Gold	Gold	Silver
Maximum Lifetime	No Limit	No Limit	No Limit	No Limit	No Limit
Deductible					*
Individual	$75	$500	$750	$1,000	$1,650
Family Maximum	$150	$1,000	$1,500	$2,000	$3,300
Coinsurance (after deductible)	80% / 20%	90% / 10%	80% / 20%	70% / 30%	50% / 50%
Out Of Pocket Max (includes PPO MEDICAL copays, deductible, coinsurance)
Individual	$475	$2,500	$3,500	$5,000	$5,000
Family Maximum	$950	$5,000	$7,000	$10,000	$10,000
Preventive Services
Preventive Physical Exam/Labs	No Copay	No Copay	No Copay	No Copay	No Copay
Preventive Child Care	No Copay	No Copay	No Copay	No Copay	No Copay
Preventive Immunizations	No Copay	No Copay	No Copay	No Copay	No Copay
Wellness Center Services	No Copay	No Copay	No Copay	No Copay	No Copay
Tele-Medicine Visit	No Copay	No Copay	No Copay	No Copay	Subj. to ded./coins.
Office Visit Copay	$10	$15	$20	$20	Subj. to ded./coins.
Chiropractic Visit Copay	$20	$20	$20	$20	Subj. to ded./coins.
Mental Health Counselor Copay	$10	$15	$20	$20	Subj. to ded./coins.
Hospital Emergency Room (ER)	$50/visit + Coinsurance	$50/visit + Coinsurance	$50/visit + Coinsurance	$50/visit + Coinsurance	Subj. to ded./coins.
Prescription Drugs	Retail (up to 31 day supply)		90 Day Supply (Mail Order or Retail)		Subj. to ded./coins.
Generic (tier 1)	$5 copay		$10 copay		(pay up front at pharmacy until deductible/coins. met)
Preferred Brand (tier 2)	25% to max of $35		$50 copay
Non-Preferred (tier 3)	45% to max of $70		$90 copay
Maximum Annual RX Copays: (After your Rx copays reach the following amount, then TCSIG pays 100% of Rx for the rest of year)
Individual	$1,000	$1,000	$1,000	$1,000	Subj. to ded./coins.
Family Maximum	$2,000	$2,000	$2,000	$2,000	Subj. to ded./coins.

* For CDHP only - per IRS guidelines, when 2 or more persons on plan, the family deductible of $3,000 must be met prior to any plan payment (except preventive paid at 100%).

This outline does not constitute the group policy and is not a contract of insurance. It explains in simple language the essential features of the group benefits provided. All rights with respect to the benefits of an insured person will be governed solely by the group policy.
Plan Document Complete Copy Glossary of Medical Coverage

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Prescription RX Co-pay structure

Prescription Co-Pay Structure at Carelon Rx offers affordable medication options with copays based on drug type. Choose from generic, preferred brand, and non-preferred brand drugs with copays ranging from $5 to $70. Enjoy savings through Retail and Mail Order Pharmacy options for 31-day and 90-day supplies. Contact Carelon Rx for more details.

Discover Co-Pay Savings

Kaiser HMO

We also offer our members the option of selecting Kaiser Permanente as an HMO option. Members on the Kaiser HMO Plan can call toll-free (800) 464-4000 with coverage questions

Visit Kaiser Permanente

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