Deductible
|
$250 Single
$750 Family
|
$250 Single
$750 Family
|
$0 Single
$0 Family
|
$1,000 Single
$3,000 Family
|
$3,600 Single
$10,800 Family
|
Coinsurance
|
You pay 20% (after deductible) Plan pays 80%
|
You pay 20% (after deductible) Plan pays 80%
|
You pay 0% (after deductible) Plan pays 100%
|
You pay 20% (after deductible) Plan pays 80%
|
You pay 40% (after deductible) Plan pays 60%
|
Out of Pocket Maximum
|
$1,500 Single
$4,500 Family
|
$1,500 Single
$4,500 Family
|
$1,500 Single
$4,500 Family
|
$7,750 Single
$18,200 Family
|
$9,100 Single
$18,200 Family
|
Office Visit Copay
|
$30 PCP
$60 Specialist
$60 Urgent Care
|
$30 PCP
$60 Specialist
$60 Urgent Care
|
$10 PCP
$45 Specialist
$45 Urgent Care
|
$50 PCP
$70 Specialist
$75 Urgent Care
|
$60 PCP
$80 Specialist
$80 Urgent Care
|
Preventive Office Copay
|
Covered at 100%
|
Covered at 100%
|
Covered at 100%
|
Covered at 100%
|
Covered at 100%
|
Emergency Room Copay
|
You pay $400/visit plus 20% coinsurance
|
You pay $400/visit plus 20% coinsurance
|
You pay $300/visit
|
You pay $500/visit plus 20% coinsurance
|
You pay $500/visit plus 40% coinsurance
|
Prescription Drug
Deductible
Cost Per Tier
|
Preferred Tier 1: No charge Tier 2: $10 copay Tier 3: $35 copay Tier 4: $75 copay
Non-preferred Tier 1: $10 copay Tier 2: $20 copay Tier 3: $55 copay Tier 4: $95 copay
Preferred specialty drugs: $150/prescription deductible does not apply
Non-preferred specialty drugs: $250/prescription deductible does not apply
|
Preferred Tier 1: No charge Tier 2: $10 copay Tier 3: $35 copay Tier 4: $75 copay
Non-preferred Tier 1: $10 copay Tier 2: $20 copay Tier 3: $55 copay Tier 4: $95 copay
Preferred specialty drugs: $150/prescription deductible does not apply
Non-preferred specialty drugs: $250/prescription deductible does not apply
|
Participating Tier 1: No charge Tier 2: $10 copay Tier 3: $50 copay Tier 3: $100 copay
Preferred specialty drugs: $150/prescription
Non-preferred specialty drugs: $250/prescription
|
Preferred Tier 1: No charge Tier 2: $10 copay Tier 3: $50 copay Tier 4: $100 copay
Non-preferred Tier 1: $10 copay Tier 2: $20 copay Tier 3: $70 copay Tier 4: $120 copay
Preferred specialty drugs: $150/prescription deductible does not apply
Non-preferred specialty drugs: $250/prescription deductible does not apply
|
Preferred Tier 1: No charge Tier 2: $10 copay Tier 3: $50 copay Tier 4: $100 copay
Non-preferred Tier 1: $10 copay Tier 2: $20 copay Tier 3: $70 copay Tier 4: $120 copay
Preferred specialty drugs: $150/prescription deductible does not apply
Non-preferred specialty drugs: $250/prescription deductible does not apply
|