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Ford Groves Schicker Automotive

Tier 1

Provider Information

https://www.semohealthnetwork.org

https://www.missouridelta.com/

https://www.sehealth.org

bjccenterofexcellence.org/providers

https://physicians.wustl.edu

Deductibles

$1,500

Employee

$4,500

Family

Max Out of Pocket

$1,500

Employee

$4,500

Family

Tier 2

Provider Information

https://www.multiplan.us/ **

Deductibles

$3,000

Employee

$9,000

Family

Max Out of Pocket

$6,000

Employee

$12,000

Family

** MultiPlan PHCS includes providers in their listings that could be in Tier 1 and may include out-of-network providers for your group or out of network for your plan. When selecting a provider from the multiplan search, please refer to your summary of benefits to verify the tier for the provider chosen to avoid out-of-network charges.

Non-Network

Provider Information

Deductibles

$6,000

Employee

$18,000

Family

Max Out of Pocket

UNLIMITED

Employee

UNLIMITED

Family

Other Services

Provider Information

Pre-certification
Vendor

844-217-8004

Telehealth
Services

https://www.memd.net

Pharmacy
Network

Ancillary Benefits

Provider Information

mybenefits.mutualofomaha.com
Vision
Dental

Other Services

Provider Information

TPA (third-party
administrator)

https://consociate.veriben.net

Pre-certification
Vendor

Precedence

800-361-1492

Telehealth
Services

https://wmthealth.com/
consociate

Pharmacy
Networks

https://southernscripts.net

Specialty Drug
Provider

https://scriptsourcing.com/enroll

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