IN-NETWORK BENEFITS |
TRADITIONAL PPO PLAN |
Deductible |
$1,000 Single $3,000 Family |
Coinsurance |
You pay 30% Plan pays 70% |
Out-of-Pocket Maximum |
$3,000 Single $9,000 Family |
Office Visit Copay |
$0 Doctor on Demand $25 PCP $25 Specialist $25 Urgent Care |
Preventive Office Copay |
Covered at 100% |
Emergency Room Copay |
$200 copay |
Prescription DrugDeductibleCost Per Tier |
$100 Single $200 Family (Waived for Tier 1)
Tier 1: $8 Tier 2: $35 Tier 3: $50 Tier 4: $50
Preferred Biosimilar/Generic Specialty: $50 Preferred Specialty: $100
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