HANCOCK COMMUNITY HEALTH PLAN

8000

$8,000 Deductible Plan: High Deductible Plan with Lower Premiums Ideal for Employers seeking to minimize premium costs and have employees who are comfortable with higher deductibles and potential out-of-pocket expenses.

Features:

$8,000 Individual / $16,000 Family Deductible: High deductible plan with significantly lower premiums.
$0 Cost Services: Continued access to essential services at no cost, encouraging utilization of preventive care.
Tier 1 Care Coordination: Guidance in selecting healthcare providers within the Hancock Health network.

Benefits:

Substantial savings on premiums for employers.
Employees can benefit from lower premiums, with the safety net of $0 cost services for key healthcare needs.
Promotes community health by utilizing local healthcare 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	$8,000 / $16,000	$8,000 / $16,000	N/A
Out of Pocket Max (Individual / Family)	$8,700 / $17,400	$8,700 / $17,400	$17,400 / $34,800	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	$40 Copay	$40 Copay	N/A
Specialist Care Visit	N/A	$80 Copay (Office) 30% Coinsurance (Outpatient Hospital)	$80 Copay (Office) N/A (Outpatient Hospital)	N/A
Chiropractic Services	N/A	$80 Copay	50% Coinsurance	Limited to 12 Visits Per Plan Year
Physical Rehabilitation	$0	$80 Copay	50% Coinsurance	Penalty for Failure to Obtain Prior Authorization Limited to 30 Visits Per Year
Mental Health Outpatient	$0	$80 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	$100 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: $55 / $110 Copay

Non-Formulary Brand: $100 / $200 Copay

Specialty: Contact Care Coordination

Rx Deductible (Individual / Family): $250 / $500

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