| Benefits at a Glance-Essential StaffCARE MVP 5500 |
| 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 (in-Patient and Out-Patient0 | 20% | 40% |
| Hospice | 20% | 40% |
| Mental Health and Substance Abuse/Behavorial Health | 20% | 40% |
| Maternity and Newborn Care | 20% | 40% |
| Laboratory Service | 20% | 40% |
| Rehabilitative and Habilitative Services/Devices | 20% | 40% |
| Emergency Services | 20% | 40% |
| PRESCRIPTIONS DRUGS (coinsurance payable by employee after the deductible |
| Generic | 20% | 40% |
| Preferred Brand | 30% | 50% |
| Non-Preferred Brand | 40% | 50% |
| Specialty | 50% | N/A |