HANCOCK COMMUNITY HEALTH PLAN

1500

HANCOCK HEALTH PLAN 1500 OVERVIEW

$1,500 Deductible Plan: Comprehensive Care with Minimal Out-of-Pocket Costs Ideal for Employers seeking to provide extensive coverage with low employee out-of-pocket expenses.

Features:

$1,500 Individual / $3,000 Family Deductible: Low deductible to minimize employee financial burden.
$0 Cost Services: Access to Direct Primary Care, X-rays, Advanced Imaging (CT/MRI/PET), Hospital Stays, Outpatient Procedures, and Childbirth and Delivery Services at no cost.
Tier 1 Care Coordination: Assistance in finding local providers within the Hancock Health system, ensuring high-quality, community-based care.

Benefits:

Enhanced employee satisfaction due to reduced out-of-pocket expenses.
Predictable healthcare costs for the employer.
Strengthened community ties by partnering with Hancock Health.

PLAN DETAILS

SERVICE	TIER 1 Hancock Health and Preferred Network	TIER 2 PHCS for VDHP or Participating Providers	TIER 3 Non-Participating Providers	LIMITS / INFO
Deductible (Individual / Family)	$0 /$0	$1,500 / $3,000	$1,500 / $3,000	N/A
Out of Pocket Max (Individual / Family)	$6,000 / $12,000	$6,000 / $12,000	$12,000 / $24,000	N/A

PHYSICIAN SERVICES

SERVICE	TIER 1 Hancock Health and Preferred Network	TIER 2 PHCS for VDHP or Participating Providers	TIER 3 Non-Participating Providers	LIMITS / INFO
Preventative Care*	N/A	$0	$0	As Outlined by the Affordable Care Act
Primary Care Visit	N/A	$25 Copay	$25 Copay	N/A
Specialist Care Visit	N/A	$45 Copay (Office) 30% Coinsurance (Outpatient Hospital)	$45 Copay (Office) 30% Coinsurance (Outpatient Hospital)	N/A
Chiropractic Services	N/A	$45 Copay	50% Coinsurance	Limited to 12 Visits Per Plan Year
Physical Rehabilitation	$0	$45 Copay	50% Coinsurance	Penalty for Failure to Obtain Prior Authorization Limited to 30 Visits Per Year
Mental Health Outpatient	$0	$45 Copay (Office) 30% Coinsurance (Outpatient Hospital)	50% Coinsurance (Office) N/A (Outpatient Hospital)	N/A
Mental Health Inpatient	$0	30% Coinsurance	30% Coinsurance	Penalty for Failure to Obtain Prior Authorization
Urgent Care	N/A	$65 Copay (Office) 30% Coinsurance (Outpatient Hospital)	50% Coinsurance (Office) N/A (Outpatient Hospital)	N/A

*Routine Adult & Child Care | Immunizations | Cancer Screenings | Mammograms | OB/GYN Visits

HOSPITAL SERVICES

SERVICE	TIER 1 Hancock Health and Preferred Network	TIER 2 PHCS for VDHP or Participating Providers	TIER 3 Non-Participating Providers	LIMITS / INFO
Diagnostic Test (X-Ray / Blood Work)	N/A (Bloodwork) $0 (X-Ray)	$50 Copay (Individual Lab) 30% Coinsurance (Outpatient Hospital)	50% Coinsurance (Individual Lab) N/A (Outpatient Hospital)	N/A
Advanced Imaging (CT / MRI / PET)	$0	30% Coinsurance	50% Coinsurance	Penalty for Failure to Obtain Prior Authorization
Emergency Room	N/A	30% Coinsurance	30% Coinsurance	N/A
Ambulance	N/A	30% Coinsurance	30% Coinsurance	N/A
Hospital Stay And Outpatient Procedures	$0	30% Coinsurance	30% Coinsurance	Penalty for Failure to Obtain Prior Authorization
Childbirth / Delivery Services	$0	30% Coinsurance	30% Coinsurance	Penalty for Failure to Obtain Prior Authorization

PRESCRIPTIONS

30/90 Day

Generics: $0 / $0 Copay

Formulary Brand: $35 / $70 Copay

Non-Formulary Brand: $75 / $150 Copay

Specialty: Contact Care Coordination

Rx 30-Day Supply is Retail Only, 90-Day Supply is Retail or Mail Order. Please See the Plan Documents for Complete Coverage Details, Limits, and Exclusions.

HANCOCK COMMUNITY HEALTH PLAN