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MSC 5500 Plan Benefits at a Glance

ANNUAL MAXIMUM Unlimited
Member Benefits In-Network Out-of-Network
Individual Deductible $5,500 $11,000
Family Deductible $11,000 $22,000
Coinsurance (payable by employee) 20% 40%
OUT-OF-POCKET MAXIMUM
Individual $6,350 $12,700
Family $12,700 $25,400
ESSENTIAL HEALTH BENEFITS (coinsurance payable by employee after deductible)
Preventive Care/Screening/Immunization (if in-network, deductible is waived) 0% 40%
Physician Office Visits 20% 40%
Ambulatory Patient Services 20% 40%
Hospitalization (inpatient and outpatient) 20% 40%
Hospice 20% 40%
Mental Health and Substance Abuse/Behavioral Health 20% 40%
Maternity and Newborn Care 20% 40%
Laboratory Service 20% 40%
Rehabilitative and Habilitative Services/Devices 20% 40%
Emergency Services 20% 40%
PRESCRIPTION DRUGS (coinsurance payable by employee after the deductible)
Generic 20% 40%
Preferred Brand 30% 50%
Non-preferred Brand 40% 50%
Specialty 50% N/A