Medical Benefits
In-Network |
Out-of-Network |
|
|---|---|---|
Deductible |
$3,000 / $6,000 |
$6,000 / $18,000 |
Coinsurance |
0% |
50% |
Out-of-Pocket Max |
$6,500 / $13,000 |
$16,000 / $48,000 |
Primary Care |
$35 Copay |
Deductible + 50% |
Routine Preventive |
Fully Covered |
Deductible + 50% |
Specialist |
$75 Copay |
Deductible + 50% |
Physician Services |
Deductible |
Deductible + 50% |
Inpatient Hospitalization |
Deductible |
Deductible + 50% |
Outpatient Surgery |
Deductible |
Deductible + 50% |
Basic Outpatient Diagnostics |
Deductible |
Deductible + 50% |
Urgent Care |
$75 Copay |
Deductible + 50% |
Emergency Room |
Deductible, then $300 Copay |
Deductible, then $300 Copay |
Prescriptions |
||
|---|---|---|
Retail Tier 1/2/3/4/5/6 (30-day supply) |
$3 / $10 / $45 / $75 / 20% up to $250 / |
Retail + 50% |
Mail Order (up to 90-day supply) |
2x Retail Copay |
2x Retail Copay |
Per Pay Period Rates (48 Pay Periods) |
|
|---|---|
Employee Only |
$58.81 |
Employee + Spouse |
$197.94 |
Employee + Child(ren) |
$181.26 |
Employee + Family |
$349.49 |
In-Network |
Out-of-Network |
|
|---|---|---|
Deductible |
$4,000 / $8,000 |
$10,000 / $30,000 |
Coinsurance |
0% |
50% |
Out-of-Pocket Max |
$7,500 / $15,000 |
$20,000 / $60,000 |
Primary Care |
Deductible |
Deductible + 50% |
Routine Preventive |
Fully Covered |
Deductible + 50% |
Specialist |
Deductible |
Deductible + 50% |
Physician Services |
Deductible |
Deductible + 50% |
Inpatient Hospitalization |
Deductible |
Deductible + 50% |
Outpatient Surgery |
Deductible |
Deductible + 50% |
Basic Outpatient Diagnostics |
Deductible |
Deductible + 50% |
Urgent Care |
Deductible |
Deductible + 50% |
Emergency Room |
$500 Copay, then Deductible |
$500 Copay, then Deductible |
Prescriptions |
||
|---|---|---|
Retail Tier 1/2/3/4/5/6 (30-day supply) |
$3 / $10 / $50 / $100 / 20% up to $250/ |
Retail + 50% |
Mail Order (up to 90-day supply) |
2x Retail Copay |
2x Retail Copay |
Per Pay Period Rates (48 Pay Periods) |
|
|---|---|
Employee Only |
$38.91 |
Employee + Spouse |
$157.13 |
Employee + Child(ren) |
$142.93 |
Employee + Family |
$286.11 |
In-Network |
Out-of-Network |
|
|---|---|---|
Deductible |
$5,500 / $11,000 |
$10,000 / $30,000 |
Coinsurance |
0% |
50% |
Out-of-Pocket Max |
$7,500 / $15,000 |
$20,000 / $60,000 |
Primary Care |
Deductible |
Deductible + 50% |
Routine Preventive |
Fully Covered |
Deductible + 50% |
Specialist |
Deductible |
Deductible + 50% |
Physician Services |
Deductible |
Deductible + 50% |
Inpatient Hospitalization |
Deductible |
Deductible + 50% |
Outpatient Surgery |
Deductible |
Deductible + 50% |
Basic Outpatient Diagnostics |
Deductible |
Deductible + 50% |
Urgent Care |
Deductible |
Deductible + 50% |
Emergency Room |
Deductible, then $500 Copay |
Deductible, then $500 Copay |
Prescriptions |
||
|---|---|---|
Preferred Generic |
Deductible, then $3 Copay |
Retail + 50% (Specialty not covered) |
Generic |
Deductible, then $10 Copay |
Retail + 50% (Specialty not covered) |
Preferred Brand |
Deductible, then $50 Copay |
Retail + 50% (Specialty not covered) |
Non-Preferred/ Preferred Specialty |
Deductible, then $100 Copay |
Retail + 50% (Specialty not covered) |
Non-Preferred Specialty |
Deductible, then 20% up to $250 for |
Retail + 50% (Specialty not covered) |
Mail Order (up to 90-day supply) |
2x Retail Copay |
2x Retail Copay |
Per Pay Period Rates (48 Pay Periods) |
|
|---|---|
Employee Only |
$29.78 |
Employee + Spouse |
$133.91 |
Employee + Child(ren) |
$120.49 |
Employee + Family |
$242.51 |