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MEDICAL PLANS
PLAN NAME
Benefits
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Preventive Office Visits
0%;
Plan pays 100%
30%*
0%;
Plan pays 100%
40%*
0%;
Plan pays 100%
40%*
0%;
Plan pays 100%
30%*
Primary Care Office Visit
$35
$30
$20
$15
Specialist Office Visit
$70
$60
$40
$30
Telemedicine Visit
$35
Not Covered
$30
Not Covered
$20
Not Covered
$15
Not Covered
Individual Deductible
(per calendar year)
$5,000
$7,500
$2,500
$5,000
$1,000
$2,000
$750
$1,500
Family Deductible
(per calendar year)
$10,000
$15,000
$7,500
$10,000
$2,000
$4,000
$1,500
$3,000
Coinsurance
Plan pays 90% Plan pays 70% Plan pays 80% Plan pays 60% Plan pays 80% Plan pays 60% Plan pays 100% Plan pays 70%
Individual Out of Pocket
Maximum
(Includes deductible and rx)
$6,350
$15,000
$5,000
$10,000
$2,500
$4,000
$750
$3,000
Family Out of Pocket
Maximum
(Includes deductible and rx)
$12,700
$30,000
$12,500
$20,000
$4,000
$8,000
$1,500
$6,000
Lifetime Maximum
Inpatient Hospital
Outpatient Surgery
Advanced Imaging Services
(MRI, MRA, CAT and PET Scans
)
$70
30%*
$60
40%*
$40
40%*
$30
30%*
Emergency Room
(facility fee only)
Urgent Care Visit
$75
30%*
$75
40%*
$75
40%*
$75
30%*
Retail Prescription Drugs
(30-day supply)
Tier 1 - Generic
$15
$15
$15
$15
Tier 2 - Preferred Brand
$25
$25
$25
$25
Tier 3 - Non-Preferred
Brand
$50
$50
$50
$50
Tier 4 - Specialty
20% to $200
maximum
20% to $200
maximum
20% to $200
maximum
20% to $200
maximum
Mail Order Prescription
Drugs
(90-day supply)
Tier 1 - Generic
$30
$30
$30
$30
Tier 2 - Preferred Brand
$50
$50
$50
$50
Tier 3 - Non-Preferred
Brand
$100
$100
$100
$100
Tier 4 - Specialty
20% to $400
maximum
20% to $400
maximum
20% to $400
maximum
20% to $400
maximum
*Coinsurance or copay applies after Deductible is met
Not Covered
Not Covered
Not Covered
Not Covered
10%*
30%*
30 visit maximum combined
30 visit maximum combined
Not Covered
Not Covered
Outpatient Therapies
(physical, occupational and
speech)
Not Covered
Not Covered
Platinum
30%*
Unlimited
$150/occurrence;
waived if admitted
30 visit maximum combined
0%*
30%*
Bronze
30%*
Unlimited
$150/occurrence;
waived if admitted
30 visit maximum combined
Unlimited
Silver
Gold
40%*
40%*
Unlimited
$150/occurrence;
waived if admitted
$150/occurrence;
waived if admitted
20%*
40%*
20%*
40%*