HANCOCK COMMUNITY HEALTH PLAN

3500

HANCOCK HEALTH PLAN 3500 OVERVIEW

$3,500 Deductible Plan: Balanced Coverage with Moderate Deductible Ideal for Employers aiming for a balance between premium costs and employee out-of-pocket expenses.

Features:

$3,500 Individual / $7,000 Family Deductible: Moderate deductible offering a balance between cost and coverage.
$0 Cost Services: Continued access to essential services at no cost.
Tier 1 Care Coordination: Support in navigating healthcare options within the Hancock Health network.

Benefits:

Cost-effective for employers while maintaining comprehensive coverage.
Employees benefit from predictable healthcare expenses.
Reinforces the employer's commitment to community health by utilizing local providers.

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	$3,500 / $7,000	$3,500 / $7,000	N/A
Out of Pocket Max (Individual / Family)	$7,000 / $14,000	$7,000 / $14,000	$14,000 / $28,000	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