Medical Benefits

Deductible
(Individual/Family)

$3,500/$7,000

$7,000/$14,000

Out-of-Pocket Max
(Individual/Family)

$8,150/$16,300

$16,300/$32,600

Member Coinsurance

20%

50%

Primary Care Visit

$25 Copay

Deductible+50%

Preventive Care

Fully Covered

Deductible+50%

Specialist Visit

$75 Copay

Deductible+50%

Inpatient Hospitalization

Deductible+20%

Deductible+50%

Outpatient Surgery

Deductible+20%

Deductible+50%

Urgent Care

$50 Copay

Deductible+50%

Emergency Room

$300 Copay, then
Deductible + Coinsurance

$300 Copay, then
Deductible + Coinsurance

Retail Prescriptions (up to 31 days)

Tier 1

$10 Copay

Tier 2

$35 Copay

Tier 3

$75 Copay

Tier 4

$250 Copay

Mail Order Prescriptions (up to 90 days)

Tier 1

$25 Copay

Tier 2

$87.50 Copay

Tier 3

$187.50 Copay

Tier 4

$625 Copay

Employee Only

$62.84

$72.84

Employee + Spouse

$153.88

$163.88

Employee + Child(ren)

$152.47

$162.47

Employee + Family

$278.51

$288.51

Deductible
(Individual/Family)

$5,000/$10,000

$10,000/$20,000

Out-of-Pocket Max
(Individual/Family)

$8,150/$16,300

$16,300/$32,600

Member Coinsurance

20%

50%

Primary Care Visit

$25 Copay

Deductible+50%

Preventive Care

Fully Covered

Deductible+50%

Specialist Visit

$75 Copay

Deductible+50%

Inpatient Hospital

Deductible+20%

Deductible+50%

Outpatient Surgery

Deductible+20%

Deductible+50%

Urgent Care

$50 Copay

Deductible+50%

Emergency Room

$300 Copay, then
Deductible + Coinsurance

$300 Copay, then
Deductible + Coinsurance

Prescription Drugs

Tier 1

$10 Copay

Tier 2

$35 Copay

Tier 3

$75 Copay

Tier 4

$250 Copay

Mail Order Drugs

Tier 1

$25 Copay

Tier 2

$87.50 Copay

Tier 3

$187.50 Copay

Tier 4

$625 Copay

Employee Only

$56.79

$66.79

Employee + Spouse

$141.18

$151.18

Employee + Child(ren)

$140.97

$150.97

Employee + Family

$260.37

$270.37

Deductible
(Individual/Family)

$5,000/$10,000

$10,000/$20,000

Out-of-Pocket Max
(Individual/Family)

$6,900/$13,800

$20,000/$40,000

Member Coinsurance

0%

50%

Primary Care Visit

Deductible, then
$25 Copay

Deductible+50%

Preventive Care

Fully Covered

Deductible+50%

Specialist Visit

Deductible, then
$75 Copay

Deductible+50%

Inpatient Hospital

Deductible

Deductible+50%

Outpatient Surgery

Deductible

Deductible+50%

Urgent Care

Deductible, then
$50 Copay

Deductible+50%

Emergency Room

Deductible, then $300 Copay

Deductible, then $300 Copay

Prescription Drugs

Tier 1

Deductible, then $10 Copay

Tier 2

Deductible, then $35 Copay

Tier 3

Deductible, then $70 Copay

Tier 4

Deductible, then $150 Copay

Mail Order Drugs

Tier 1

Deductible, then $25 Copay

Tier 2

Deductible, then $87.50 Copay

Tier 3

Deductible, then $175 Copay

Tier 4

Deductible, then $375 Copay

Employee Only

$46.28

$56.28

Employee + Spouse

$119.11

$129.11

Employee + Child(ren)

$121.01

$131.01

Employee + Family

$228.84

$238.84