NCBA - Component 1: Apex HDHP Basic MEC and Advantage Plan

HDHP / 100% Preventive
Advantage Plan
HSA Compatible
HDHP / 100% PreventiveYes
Advantage PlanNot Applicable
Annual Deductible
HDHP / 100% Preventive$3,000 Ind / $6,000 Family
Advantage PlanNot Applicable
Coinsurance
HDHP / 100% Preventive80% of Negotiated Rate
Advantage PlanNot Applicable
Annual Out-of-Pocket maximum
HDHP / 100% PreventivePhysician Office Visit (Primary Care), Laboratory Services, Urgent Care Only
Advantage PlanNot Applicable
Preventive Care Services
21 Preventive Services for Adults
HDHP / 100% Preventive100% Coverage, no Copay for Mandated Preventive Care Services
Advantage Plan100% Coverage, no Copay for Mandated Preventive Care Services
28 Preventive Services for Women
HDHP / 100% Preventive100% Coverage, no Copay for Mandated Preventive Care Services
Advantage Plan100% Coverage, no Copay for Mandated Preventive Care Services
31 Preventive Services for Children
HDHP / 100% Preventive100% Coverage, no Copay for Mandated Preventive Care Services
Advantage Plan100% Coverage, no Copay for Mandated Preventive Care Services
PPO Network: PHCS
Primary Care Office Visit
HDHP / 100% PreventiveNot Covered
Advantage Plan$20 Copay
(Max 3 visits per calendar year)
Specialists Office Visit
HDHP / 100% PreventiveNot Covered
Advantage Plan$50 Copay
(Max 3 visits per calendar year)
Urgent Care
HDHP / 100% PreventiveNot Covered
Advantage Plan$50 Copay
(Max 3 visits per calendar year)
Diagnostic X-Ray & Laboratory Services
HDHP / 100% PreventiveNot Covered
Advantage Plan$50 Copay by Date of Service
(Max 5 Services per calendar year)
* CT Scan or ¹MRI
HDHP / 100% PreventiveNot Covered
Advantage Plan$200 Copay
(Max 1 MRI or CT Scan per calendar year)
* 3D MRIs are not covered. Enhanced imaging services, the use of a contrast material to enhance the MRI or CT Scan is not a covered service. The base MRI or CT Scan only are covered
Prescription Drug Benefits - WelldyneRx®
Tier 1 – Low Cost Generics
HDHP / 100% PreventiveNot Covered
Advantage Plan$1 Copay
Tier 2 - Generics
HDHP / 100% PreventiveNot Covered
Advantage Plan10% Coinsurance
Tier 3 - Preferred Brand
HDHP / 100% PreventiveNot Covered
Advantage Plan20% Coinsurance
Tier 4 – Non-Preferred Brand
HDHP / 100% PreventiveNot Covered
Advantage Plan40% Coinsurance
Tier 5 – Specialty, Generic and Preferred
HDHP / 100% PreventiveNot Covered
Advantage Plan10% Coinsurance
(Plan pays 90% up to a max of $150 per Rx)
Tier 6 – Non-Preferred Specialty
HDHP / 100% PreventiveNot Covered
Advantage Plan20% Coinsurance
(Plan pays 80% up to a max of $250 per Rx)
Membership/Contribution Fee
Member Only
HDHP / 100% Preventive$95.31
Advantage Plan$166.53
Member + Child(ren)
HDHP / 100% Preventive$125.92
Advantage Plan$236.42
Member + Spouse
HDHP / 100% Preventive$125.92
Advantage Plan$252.74
Member + Family
HDHP / 100% Preventive$125.92
Advantage Plan$329.33