Medical Benefit Summary
Medical Provider: CFA
Customer Service Quantum Health Care Coordinators: (888) 496-9097
Website: www.mysinclairbenefits.com
Rx Provider: CVS/Caremark
Group # RX23HB
Customer Service Number: (844) 268-1976
Website: www.caremark.com
Brand Name Rx Provider: CRX International
Customer Service Number: (866) 488-7874
Website: www.crxintl.com
WebID: SINCLAIR
Middle Option PPO Benefit Summary
| Medical Benefit | In-Network | Out-of-Network |
|---|---|---|
| Deductible | $750 (3/Family) | $1,125 (3/Family) |
| Co-Insurance | 80%/20% | 60%/40% |
| Physician’s Office Visit | $25 co-pay | Deductible & Co-Ins. |
| Specialist Visit | $35 co-pay | Deductible & Co-Ins. |
| MDLIVE | $5 co-pay | N/A |
| Well Child Care (thru age 2) | 100% | 100% |
| Adult Wellness (age 3+) | 100% | 100% |
| Women’s Preventive Care | 100% | 100% |
| Inpatient Care | $250 co-pay, Deductible & Co-Ins. | $200 co-pay, Deductible & Co Ins. |
| Outpatient Surgery | $150 co-pay, Deductible & Co-Ins. | Deductible & Co-Ins |
| Urgent Care | $25 co-pay | $25 co-pay |
| Rx Out-Of-Pocket Maximum | $3,700 – Individual $7,400 – Family | N/A |
| Prescriptions | $16/$50/$80/$140 – Retail $32/$100/$160 / N/A – Mail | |
| Emergency Room* | $175 co-pay & 80%/20% Co-Ins. | $175 co-pay & 80%/20% Co-Ins. |
| Lifetime Maximum | Unlimited | Unlimited |
| Out-Of-Pocket Maximum | $3,000 – Individual $6,000 – Family | $4,000 – Individual $8,000 – Family |
* Non-emergency use of the emergency room services requires $150 co-pay per visit plus co-insurance.
This summary is a general outline. Please refer to the policy contract and benefit booklet for exact details and limitations.