| Plan Name | USCFL Health Plan-Part A |
|
| Activity | Benefit | |
| All USCFL Practices, Scrimmages, and Competition Related Health Care | 100% Coverage for all Services | |
| Plan (for USCFL Health Plan-Part B, Schedule 2) | Annual Premium (You Pay) |
| Reserve (Individual) | $600 ($25 per pay period) |
| Reserve plus Spouse or Dependant Coverage (1) | $1,200 ($50 per pay period) |
| Reserve plus Family Coverage (1) | $1,680 ($70 per pay period) |
| Plan Name | USCFL Health Plan-Part B, Schedule 2 |
||
| In Network You Pay |
Out of Network You Pay |
||
| Cash Deductible per Plan Year (Individual) (2) | $200 | $400 | |
| Cash Deductible per Plan Year (Family) (2) | $600 | $1,200 | |
| Maximum Out-of-Pocket Expense per Plan Year (Individual) | $2,500 | $5,000 | |
| Maximum Out-of-Pocket Expense per Plan Year (Family) | $5,000 | $10,000 | |
| Outpatient Services | In Network You Pay (Co-insurance) |
Out of Network You Pay (Co-insurance) |
|
| Office Visits (Primary Care) | $25 (no deductible) | $30 (no deductible) | |
| Office Visits (Specialist) | $40 (no deductible) | $50 (no deductible) | |
| Emergency Room (3) | 20% (after deductible) | 30% (after deductible) | |
| Emergency Room (Non-emergency) | 30% (after deductible) | 40% (after deductible) | |
| Ambulance (3) | 20% (after deductible) | 30% (after deductible) | |
| Ambulance (Non-emergency) | 30% (after deductible) | 40% (after deductible) | |
| Urgent or Convenient Care | 20% (after deductible) | 30% (after deductible) | |
| Urgent or Convenient Care (Non-urgent) | 30% (after deductible) | 40% (after deductible) | |
| Routine Prenatal Care | 20% (after deductible) | 30% (after deductible) | |
| Preventive Physicals | $0 | $0 | |
| Wellness Services | $0 | $0 |
|
| Mammography | $0 | $0 | |
| Outpatient & Diagnostic testing | 20% (after deductible) | 30% (after deductible) | |
| Outpatient Surgeries/Procedures | 20% (after deductible) | 30% (after deductible) | |
| Spinal Manipulations | 20% (after deductible) | 30% (after deductible) | |
| Outpatient Mental Health Care (4) | $40 (no deductible) | $50 (no deductible) | |
| Durable Medical Equipment | 20% (after deductible) | 30% (after deductible) | |
| Inpatient Services | In Network You Pay (Co-insurance) |
Out of Network You Pay (Co-insurance) |
|
| Hospitalization | 20% (after deductible) | 30% (after deductible) | |
| Maternity | 20% (after deductible) | 30% (after deductible) | |
| Extended Care/Rehabilitation | 20% (after deductible) | 30% (after deductible) | |
| Mental Health Care | 20% (after deductible) | 30% (after deductible) | |
| Substance Abuse Treatment | 20% (after deductible) | 30% (after deductible) | |
| Prescription Drug Pharmacy Services | In Network You Pay (Co-payment) |
Out of Network You Pay (Co-insurance) |
|
| Cash Deductible per Plan Year (Individual) | $0 | $100 | |
| Cash Deductible per Plan Year (Family) | $0 | $300 | |
| Generic Prescriptions | $10 |
20% (after deductible) | |
| Name-Brand Preferred Prescriptions | $20 |
30% (after deductible) | |
| Name-Brand Non-preferred Prescriptions | $30 |
40% (after deductible) | |