Medical Plan Administrator: Meritain Health 

Group #: 12967
Customer Service: 800-925-2272
Log In (EOB, Claim Status, Lookup Costs, Find Provider): 
Web www.meritain.com

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Summary Plan Description
Summary of Benefits & Coverage

Deductible (Per Year)*

In-Network:
Individual: $300
​Family: $600
Out-of-Network:
Individual: $600
Family:  $1,800

Co-Pays (In Network)*

Office Visit: $25 Copay 
Lab, X-Ray, and Diagnostic (outpatient): 20% after Deductible 
Urgent Care: $50 Copay, then 20%; Deductible waived 
Physical Therapy:  20% after Deductible
Manipulative Treatment: $25 Copay 
Massage Therapy: $25 Copay

Out-of-Pocket Limit (Per Year)*

In-Network:  
Individual: $3,000
Family: $9,000
Out-of-Network:
Individual: $6,000
Family: $18,000

​Co-Pays​ (In Network)*

​Physician Fees for Surgical & Medical Services: 20% after Deductible
Major Diagnostic & Imaging (outpatient):  20% after Deductible
ER: $100 Copay, then 20% (50% non-emergent care); Deductible waived 
Mental Health (Inpatient): 20% after Deductible
Hospital Inpatient Stays:   20% after Deductible

Prescription Drugs (In Network)* 

Retail (In-Network)
Up to 30 day supply 
Generic: 100% ($0 Copay) 
Formulary:  $25 Copay
Non-Formulary:  $50 Copay
Mail Order (In-Network)
​Up to 90 day supply
Generic:  $30 Copay
Formulary :  $50 Copay
Non-Formulary​:  $80 Copay
This web site is not a legal document.  This web site is not a guarantee of coverage, eligibility, or provider status and is designed for informational illustration only.  Benefits outlined on this web site are subject to change at any time.  Please consult your benefit plan provider(s) or administrator(s) for legal documents regarding your plan and to check coverage and/or eligibility.