Medical Benefits

Deductible
(Individual/Family)

$500/$1,000

Out-of-Pocket Max
(Individual/Family)

$5,000/$10,000

Member Coinsurance

20%

Primary Care Visit

$35 Copay/Visit

Preventive Care

0%

Specialist Visit

$70 Copay/Visit

Telehealth

Paid at 100% of the allowable charge

Physician Services

Deductible then 20%
Coinsurance

Inpatient Hospitalization

Deductible then 20%
Coinsurance

Outpatient Surgery

Deductible then 20%
Coinsurance

Basic Outpatient Diagnostics

Paid at 100% of the allowable charge up to a combined maximum of $300 for each
covered person, each benefit period.

Urgent Care

Copay is applicable to the provider type

Emergency Room

$250 Copay then
Deductible and 20%
Coinsurance

Tier 1

$15 Copay

2.5x Retail

Tier 2

$50 Copay

2.5x Retail

Tier 3

$75Copay

2.5x Retail

Tier 4

Preferred: $150 Copay
Non-Preferred: 20% Coinsurance up to $250 Copay

2.5x Retail

Employee Only

$51.25

Employee + Spouse or Domestic Partner

$162.15

Employee + Child(ren)

$151.90

Family

$262.05

Deductible
(Individual/Family)

$1,000/$2,000

Out-of-Pocket Max
(Individual/Family)

$5,000/$10,000

Member Coinsurance

20%

Primary Care Visit

$35 Copay/Visit

Preventive Care

0%

Specialist Visit

$70 Copay/Visit

Telehealth

Paid at 100% of the allowable charge

Physican Services

Deductible then 20% Coinsurance

Inpatient Hospitalization

Deductible then 20% Coinsurance

Outpatient Surgery

Deductible then 20% Coinsurance

Basic Outpatient Diagnostics

Paid at 100% of the allowable charge up to a combined maximum of $300 for each
covered person, each benefit period

Urgent Care

Copay is applicable to
the provider type

Emergency Room

$250 Copay then
Deductible and 20%
Coinsurance

Tier 1

$15 Copay

2.5x Retail

Tier 2

$50 Copay

2.5x Retail

Tier 3

$75 Copay

2.5x Retail

Tier 4

Preferred: $150 Copay

Non-Preferred: 20% Coinsurance up to $250 Copay

2.5x Retail

Employee Only

$45.10

Employee + Spouse or Domestic Partner

$148.60

Employee + Child(ren)

$138.40

Family

$242.45

Deductible
(Individual/Family)

$1,500/$3,000

Out-of-Pocket Max
(Individual/Family)

$5,000/$10,000

Member Coinsurance

20%

Primary Care Visit

$35 Copay/Visit

Preventive Care

0%

Specialist Visit

$70 Copay/Visit

Telehealth

Paid at 100% of the allowable charge

Physican Services

Deductible then 20% Coinsurance

Inpatient Hospitalization

Deductible then 20% Coinsurance

Outpatient Surgery

Deductible then 20% Coinsurance

Basic Outpatient Diagnostics

Paid at 100% of the allowable charge up to a combined maximum of $300 for each
covered person, each benefit period

Urgent Care

Copay is applicable to the provider type

Emergency Room

$250 Copay then
deductible and 20%
Coinsurance

Tier 1

$15 Copay

2.5x Retail

Tier 2

$50 Copay

2.5x Retail

Tier 3

$75 Copay

2.5x Retail

Tier 4

Preferred: $150 Copay

Non-Preferred: 20% Coinsurance up to $250 Copay

2.5x Retail

Employee Only

$40.25

Employee + Spouse or Domestic Partner

$137.65

Employee + Child(ren)

$128.55

Family

$225.30

Deductible
(Individual/Family)

$3,300/$6,600

Out-of-Pocket Max
(Individual/Family)

$6,350/$12,700

Member Coinsurance

0%

Primary Care Visit

Deductible

Preventive Care

Paid at 100% of allowable charge

Specialist Visit

Deductible

Telehealth

Deductible

Physican Services

Deductible

Inpatient Hospitalization

Deductible

Outpatient Surgery

Deductible

Basic Outpatient Diagnostics

Deductible

Urgent Care

Deductible

Emergency Room

Deductible

Tier 1

$15 Copay

2.5x Retail

Tier 2

$50 Copay

2.5x Retail

Tier 3

$75 Copay

2.5x Retail

Tier 4

Preferred: $150 Copay

Non-Preferred: 20% Coinsurance up to $250 Copay

2.5x Retail

Employee Only

$24.55

Employee + Spouse or Domestic Partner

$101.25

Employee + Child(ren)

$94.05

Family

$170.10